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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. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.
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A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?
- A. Prefers not to look at the stoma site
- B. Participates in performing ostomy care
- C. Denies feelings of sadness about the ostomy
- D. Accepts that sexual activity will decrease
Correct Answer: B
Rationale: Participating in ostomy care demonstrates acceptance and adaptation to the altered body image.
A nurse is collecting data from a client who is taking enoxaparin. The client reports starting the use of dietary supplements. The nurse should report the use of which of the following supplements to the provider?
- A. Ginkgo biloba
- B. Flaxseed powder
- C. Probiotics
- D. Echinacea
Correct Answer: A
Rationale: Ginkgo biloba can increase the risk of bleeding when taken with enoxaparin, an anticoagulant, and should be reported to the provider.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. It is common for the skin on my breasts to dimple.
- B. I will perform breast exams every other month.
- C. It is common for one breast to be larger than the other.
- D. I will perform breast exams the day my period begins.
Correct Answer: C
Rationale: It is normal for one breast to be slightly larger than the other, reflecting an understanding of breast self-examination teaching.
A nurse is reinforcing teaching about saturated fats with a client who is at risk for cardiovascular disease. Which of the following cooking fats should the nurse recommend the client use?
- A. Canola oil
- B. Butter
- C. Vegetable shortening
- D. Lard
Correct Answer: A
Rationale: Canola oil is low in saturated fat and heart-healthy, unlike butter, shortening, or lard, reducing cardiovascular risk.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Keep both arms below the level of the client's heart.
- B. Obtain blood pressure readings using the client's right arm.
- C. Use the client's left arm to obtain blood samples.
- D. Limit range-of-motion exercises with the affected arm
Correct Answer: C
Rationale: Using the left arm for blood samples avoids trauma to the right arm, reducing the risk of lymphedema after a right mastectomy.