Nokea
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- D. Platelets 60,000/mm³ (150,000 to 400,000/mm³)
Correct Answer: D
Rationale: Liver biopsy carries bleeding risk due to the organ's vascularity, so clotting ability is critical. Platelets at 60,000/mm³ are severely low (normal 150,000-400,000/mm³), increasing hemorrhage risk post-procedure. Bilirubin (1.0 mg/dL) and AST (34 units/L) are within normal limits, reflecting liver function but not bleeding tendency. Ammonia (55 mcg/dL) is normal, relevant to encephalopathy, not biopsy safety. Thrombocytopenia below 100,000/mm³ often prompts transfusion or delay per procedural protocols, as platelets are vital for hemostasis. Reporting this to the provider ensures risk assessment potentially canceling or modifying the biopsy prioritizing patient safety over proceeding with normal liver markers, making it the critical value to escalate.
You may also like to solve these questions
A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
Correct Answer: B
Rationale: Post-transurethral resection of the prostate (TURP), teaching focuses on healing and preventing complications like bleeding or infection. Waiting 6 weeks before resuming sexual intercourse allows the prostatic fossa to heal, reducing risks of hemorrhage or irritation, a standard guideline post-TURP. Ibuprofen, an NSAID, increases bleeding risk by inhibiting platelet function, contraindicated with fresh surgical sites. Tub bathing with a catheter risks introducing bacteria into the urinary tract, so showers are preferred until removal. Driving after 1 week may be premature recovery varies, and catheter presence or pain could impair safety; typically, 2-4 weeks is advised. The 6-week sexual abstinence instruction aligns with urologic care protocols, promotes safe recovery, and addresses a common patient concern, making it the most appropriate teaching point to ensure long-term outcomes and minimize rehospitalization.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?
- A. Replace the unit when the drainage chamber is full.
- B. Monitor for at least 150 mL of drainage every hour.
- C. Clamp the tube for 30 min every 8 hr.
- D. Pin the tubing to the client's bed sheets.
Correct Answer: A
Rationale: Closed-chest tube systems manage pleural fluid or air, requiring patency and safety. Replacing the unit when the drainage chamber is full maintains system function overflow risks backpressure or infection, per manufacturer guidelines. Monitoring for 150 mL/hr is excessive; normal drainage tapers post-insertion, and sudden high output signals bleeding, not a routine action. Clamping the tube risks tension pneumothorax by trapping air or fluid, only done briefly under specific orders (e.g., checking for leaks). Pinning tubing to sheets prevents dislodgement but isn't the primary maintenance action. Full chamber replacement ensures continuous drainage, aligns with infection control (e.g., CDC standards), and prevents complications like lung collapse, making it the nurse's key responsibility in chest tube care.
A nurse is caring for a client who has dysphagia following a stroke. When assisting the client at mealtime, which of the following actions should the nurse plan to take?
- A. Instruct the client to tilt their head back to facilitate swallowing
- B. Encourage the client to use a straw.
- C. Provide oral care before meals.
- D. Schedule physical therapy directly before meals.
Correct Answer: C
Rationale: Oral care before meals removes debris and reduces aspiration risk in dysphagia. Tilting back worsens swallowing, straws may not be safe, and therapy timing isn't relevant.
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL. Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Tingling of the fingers
- B. Positive Trousseau's sign
- C. Increased respiratory rate
- D. Dizziness upon standing
- E. Hypotension
- F. Muscle weakness
- G. Dry mouth
Correct Answer: C
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for acidosis in diabetic ketoacidosis.
A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?
- A. Absence of Chvostek's sign
- B. Presence of Kussmaul respirations
- C. Presence of diaphoresis
- D. Absence of urinary ketones
Correct Answer: B
Rationale: Kussmaul respirations indicate hyperglycemia-induced metabolic acidosis as the body compensates for high glucose. Chvostek's is unrelated, diaphoresis suggests hypoglycemia, and ketones may be present but aren't definitive here.