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) Helps maintain muscle tone and promotes overall well-being without overstressing the body during recovery from hepatitis B.
B) Antibiotics are not effective against viruses like hepatitis B.

C) There is generally no need to restrict fluids in hepatitis B; adequate hydration supports overall health and liver function.

D) A high-fat diet is not recommended for liver disease; typically, a balanced, low-fat diet is more appropriate.

A. Assess level of consciousness B. Assess for bleeding C. Measure abdominal girth D. Auscultate bowel sounds

Correct Answer is A

Explanation

A) Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment.
B) The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia.
C) This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario.
D) While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.

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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

A nurse is planning care for a client who has hepatitis B. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

The nurse is providing care to a client admitted with chronic pancreatitis. Which items are appropriate to include in the discharge teaching for this client? Select all that apply.

When planning care for a client receiving an enteral feeding via jejunostomy tube, which intervention would the nurse include?

The nurse notes these laboratory results for a client with cirrhosis: PT 20 seconds (11-12.5 sec) and serum ammonia 35 mcg/dL (15-45 mcg/dL). What action by the nurse would be a priority?

The nurse is preparing a client presentation regarding pancrelipase (Viokase) therapy. Which information would the nurse include in the teaching session?

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 making a home visit to a client with chronic pancreatitis. Which data is consistent with this diagnosis?

The nurse is admitting a client diagnosed with ascites. Which assessment finding would the nurse anticipate?

The nurse is preparing a community presentation about hepatitis B virus (HBV). Which information should be included in the teaching session?