The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?

Evaluate for asterixis

Palpate for peripheral edema

Evaluate for decreased level of consciousness

Inspect for petechiae

Answer and Explanation

The Correct Answer is B

Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.

Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.

Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.

Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.

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Correct Answer is C

Explanation

Choice A: Topical ointment Topical ointment forms of nitroglycerin are used for their long-acting effects. The medication is absorbed slowly through the skin, providing a steady level of drug in the bloodstream. This form is not designed for rapid relief of acute angina attacks but rather for prevention.

Choice B: Sustained-release Sustained-release forms of nitroglycerin are designed to release the medication slowly over an extended period. This route is also not suitable for treating acute symptoms because it does not provide immediate relief but is used for long-term management of angina pectoris. Nitroglycerin is a medication used primarily to treat angina pectoris (chest pain) and heart failure. It works by relaxing the smooth muscles and dilating the blood vessels, which increases blood flow to the heart and decreases its workload. The route of administration can significantly affect the onset and duration of the medication’s action.

Choice C: Sublingual The sublingual route, where the medication is placed under the tongue, allows for rapid absorption into the bloodstream through the rich supply of blood vessels found in the area. This form of nitroglycerin acts quickly, usually within 1 to 3 minutes, and is the preferred choice for immediate relief of angina pain. When rapid onset is required for relief from acute angina symptoms, the sublingual route is the most appropriate choice for administering nitroglycerin. It provides quick absorption and fast action, making it an essential treatment option for patients experiencing chest pain due to angina.

Choice D: Transdermal patch Transdermal patches release nitroglycerin slowly through the skin and into the bloodstream. Like topical ointments and sustained-release forms, they are used for long-term prophylaxis of angina and not for rapid relief.

A. "A headache is an indication of an allergy to the medication." B. "A headache is an expected adverse effect of the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache indicates tolerance to the medication."

Correct Answer is B

Explanation

Choice A reason:

A headache is not typically an indication of an allergy to nitroglycerin. Allergic reactions are more likely to present with symptoms such as rash, itching, or difficulty breathing.

Choice B reason:Headaches are a well-known side effect of nitroglycerin, due to its vasodilating effects, which can cause dilation of cerebral arteries.

Choice C reason:While anxiety can cause headaches, in this context, where the client has taken nitroglycerin, it is more likely that the headache is a side effect of the medication rather than anxiety.

Choice D reason:Tolerance to medication would reduce the effectiveness of the drug, not typically cause a headache. The headache is a common side effect, not an indication of tolerance.

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The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client?

Correct Answer is C

Explanation

A nurse in the emergency department is caring for a client who took three nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now is experiencing a headache. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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