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 D

Explanation

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.

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 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

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?

Correct Answer is D

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

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