The nurse is caring for a client who has been admitted after an acetaminophen overdose. Which of the nurse's assessment findings suggest liver damage? (Select all that apply.)
The client's skin and eyes are visibly jaundiced.
The client's AST and ALT levels are elevated.
The client's temperature is 102.5° F (39.2° C).
The client has an elevated red blood cell count.
The client's eyes are sensitive to light.
Correct Answer : A,B
A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An INR of 5.0 indicates a significantly increased risk of bleeding, and administering vitamin K is the appropriate antidote for reversing the effects of warfarin. This is a critical intervention to restore coagulation.
B. Increasing the dose of warfarin is inappropriate in this scenario because the INR is already elevated; it would further increase bleeding risk.
C. While heparin can be used for anticoagulation, it is not appropriate to administer it while the INR is dangerously high without reversing the warfarin first.
D. Continuing warfarin is unsafe at this INR level due to the high risk of bleeding; monitoring for symptoms without intervention is not adequate care.
Correct Answer is ["28"]
Explanation
Infusion rate (gtt/min) = (Infusion rate (mL/hr) Drop factor (gtt/mL)) / 60
In this case:
- Infusion rate (mL/hr) = 85 mL/hr
- Drop factor (gtt/mL) = 20 gtt/mL
Plugging the values into the formula:
- Infusion rate (gtt/min) = (85 mL/hr 20 gtt/mL) / 60 = 28.33 gtt/min
Rounding to the nearest whole number, the infusion rate is 28 gtt/min.
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