Nurses’ Notes 1200: Client has a history

Nurses’ Notes 1200: Client has a history of cirrhosis of the liver for the past 5 years. Client admitted to the medical-surgical unit for weight gain, vomiting, and worsening ascites. Client is lethargic and orientated only to self and place. Client has profound abdominal distention including a protruding umbilicus and taut skin. Client is jaundice throughout. The client nods ‘yes’ when asked if they are in pain but cannot give a pain level. +1 pitting edema noted in bilateral lower extremities. Bilateral pedal pulses are +2. Client is dyspneic, bilateral crackles auscultated in bilateral lower bases. 1215: AST: 351 units/L (0 – 35 units/L) ALT: 256 units/L (4 – 36 units/L) Total bilirubin: 3.6 mg/dL (0.3 – 1.0 mg/dL) Albumin: 1.6 g/dL (3.5 – 5 g/dL) Ammonia: 175 mcg/dL (10 – 80 mcg/dL) Complete the following sentence by using the list of options. The nurse should first address the client’s (select one): Pain Fluid Volume status Bilirubin Followed by the client’s: (select one) Cardiac status Neurological status Jaundice answer this two questions 1. which findings in the Nurse’s 0900 notes require immediate follow up by the nurse? Briefly explain your rationale. my answer is fluid overload but I need help for the rationale 2. which findings in the 0900 Lab results require immediate follow up by the nurse? Briefly explain your rationale. my answer is neurological status, but i need help for rationale

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