Difficulty: Medium
Average Score: 80%
Simulated
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?
Correct answer
C
Rationale
While important, it is not directly related to the coagulopathy indicated by the prolonged PT. Important for overall fluid management but not directly related to the risk of bleeding. With a significantly prolonged PT, assessing for signs of gastrointestinal bleeding is a priority. Important for safety, but the immediate risk of bleeding due to coagulopathy takes precedence.