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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A) Limited activity is not typically necessary unless specified by a physician.
B) A low-fat diet is usually recommended for a client with chronic pancreatitis.
C) Weight loss in chronic pancreatitis is common due to the risk of malnutrition and malabsorption.
D) Administration of pancrelipase is essential for aiding digestion if the pancreas is not producing enough enzymes.
E) Elimination of alcohol intake is critical to prevent further damage to the pancreas.
Correct Answer is C
Explanation
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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