The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Request a dietary consult

Order a 2 gram sodium restriction diet

Initiate a fluid restriction

Hold the spironolactone and furosemide

Answer and Explanation

The Correct Answer is D

A) Requesting a dietary consult is useful but not the most immediate action needed.

B)   Ordering a 2 gram sodium restriction diet is important but not addressing the immediate issue of electrolyte imbalance.
C)   Fluid restriction may be considered but not before addressing the electrolyte issues.
D)   Holding the spironolactone and furosemide is the correct action, as administering these could exacerbate the existing hypokalemia and hyponatremia, increasing the risk of adverse effects.

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Correct Answer is A

Explanation

A) Gallstones are a leading cause of acute pancreatitis as they can block the pancreatic duct.
B) While inflammation of the duodenum can cause abdominal symptoms, it does not directly lead to acute pancreatitis.
C) Diabetes results from the dysfunction of the pancreas after damage but does not cause acute pancreatitis.
D) Hepatitis C affects the liver and does not directly cause pancreatitis.

A. Risk for bleeding B. Risk for activity intolerance C. Risk for impaired nutrition: less than body requirements D. Risk for impaired skin integrity

Correct Answer is A

Explanation

A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.

B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.

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The nurse is preparing to administer spironolactone (Aldactone) and furosemide (Lasix) at 0900 to a client diagnosed with ascites. Review of 0600 laboratory results shows serum sodium 130 mEq/L (136-145 mEq/L) and potassium 3.1 mEq/L (3.5-5.0 mEq/L). Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting a health history of a client admitted for possible acute pancreatitis. Which health history item would increase the client's risk for this diagnosis?

Correct Answer is A

Explanation

A client with cirrhosis has the following current assessment data: jaundice, decreased appetite, hemoglobin 15 g/dL (14-18 g/dL) and PT of 20.6 seconds (11-12.5 sec). What does the nurse identify as the priority problem for this client?

Correct Answer is A

Explanation

A client with cirrhosis is scheduled to receive a third dose of lactulose (Cephulac) at 1800. Which current finding would cause the nurse to question administering this medication?

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

A client with a history of chronic pancreatitis reports weight loss of 10 pounds over the last month and foul smelling stools. What would be a priority action for the nurse to take?

The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?

A client with cirrhosis has the following laboratory results: albumin 4.9 g/dl. (3.5-5 g/dL), PT 13 seconds (11-12.5 sec), and serum ammonia 68 mcg/dL (15-45 mcg/dL). Based on this information, what is the nurse's next action?

The nurse should evaluate results of which laboratory tests while caring for a client who has cirrhosis of the liver? Select all that apply.

The nurse is admitting a client with the diagnosis of hepatic encephalopathy. Which assessment finding should the nurse anticipate?

A female client is visiting the Medical Clinic with suspected hepatitis C. Which assessment question should the nurse ask this client?