Difficulty: Medium
Average Score: 77%
Simulated
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
A
Rationale
Elevated serum ammonia levels can lead to hepatic encephalopathy, which affects mental status and consciousness, making this the priority assessment. The PT is slightly prolonged but not alarmingly high; bleeding is less of a concern compared to the elevated ammonia. This action is important in assessing fluid accumulation but is not as critical as assessing mental status in this scenario. While part of a comprehensive abdominal assessment, this is not the most critical action given the elevated ammonia level.