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?

Auscultate lungs

Monitor I&O

Check stools for blood

Initiate fall precautions

Answer and Explanation

The Correct Answer is C

A)   While important, it is not directly related to the coagulopathy indicated by the prolonged PT.
B)   Important for overall fluid management but not directly related to the risk of bleeding.
C)   With a significantly prolonged PT, assessing for signs of gastrointestinal bleeding is a priority.

D)   Important for safety, but the immediate risk of bleeding due to coagulopathy takes precedence.

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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.

A. Pregnant women may pass HBV to the fetus B. Maintain safe food-handling procedures C. Symptoms include diarrhea and cramping D. History of gallstones is a risk factor

Correct Answer is A

Explanation

A) HBV can be transmitted from an infected mother to her child during childbirth.

The importance of screening and vaccination should be emphasized.

B) While important for general health, this is not specifically related to the transmission of HBV, which is primarily spread through blood and bodily fluids.
C) These are not typical symptoms of HBV; common symptoms include jaundice, fatigue, and abdominal pain.
D) History of gallstones is not a risk factor for HBV.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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

Correct Answer is A

Explanation

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

What does the nurse identify as a potential complication of chronic pancreatitis?

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

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?

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?

An adult client is admitted to the emergency department with symptoms of acute pancreatitis. Which data support this diagnosis?