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
Explanation
A) Monitoring for hypertension is not directly related to caring for a client with enteral feeding via a jejunostomy tube.
B) Measuring residual volume is a nursing intervention for clients with gastric feeding tubes, not jejunostomy tubes.
C) Diarrhea is a potential complication of enteral feeding, and monitoring stool output is essential to assess for this complication and adjust feeding accordingly.
D) Monitoring blood glucose levels is important for clients with diabetes but is not specific to caring for a client with enteral feeding via a jejunostomy tube.
Correct Answer is A
Explanation
A) Chronic damage to the pancreas can lead to diabetes mellitus due to the destruction of insulin-producing cells.
B) Jaundice is typically associated with liver disease, not directly linked with chronic pancreatitis.
C) Ascites is a complication of liver disease, not typically a direct result of chronic pancreatitis.
D) While steatorrhea is a symptom of chronic pancreatitis due to malabsorption of fats, it is not a complication but rather a direct effect of the enzyme insufficiency.
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