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?
Ammonia 55 mcg/dL
Platelets 60,000/mm²
Aspartate aminotransferase 34 units/L
Bilirubin 1.0 mg/dL
The Correct Answer is B
A platelet count of 60,000/mm² is below the expected reference range, and the nurse should report this value to the provider. Ammonia, aspartate aminotransferase, and bilirubin values are within expected reference ranges and do not require further reporting.
Other choices are not correct because:
A. Ammonia 55 mcg/dL: Is within the expected reference range and does not require further reporting.
C. Aspartate aminotransferase 34 units/L: Is within the expected reference range and does not require further reporting.
D. Bilirubin 1.0 mg/dL: Is within the expected reference range and does not require further reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Applying traction weight to the external fixator is not recommended, as it can cause excessive stress on the pins and wires, leading to complications such as infection, loosening, or breakage1.Traction is usually applied to skeletal pins that are inserted into the bone without an external frame2.
Choice B rationale: Monitoring the neurovascular status of the affected limb is important, but every 8 hours is not frequent enough.The nurse should perform neurovascular checks every 2 to 4 hours for the first 24 hours, then every 4 to 8 hours, according to the facility policy3. This is to assess for signs of nerve damage, compartment syndrome, or impaired circulation, which can result from the injury or the device.
Choice C rationale: Administering pain medication 30 min prior to pin care is a correct intervention, as it can help reduce the discomfort and anxiety associated with the procedure. Pin care involves cleaning the pin sites with an antiseptic solution and applying sterile dressings to prevent infection and promote healing. The frequency and technique of pin care may vary depending on the type of device, the condition of the wound, and the facility protocol.
Choice D rationale: Adjusting the clamps on the device’s frame daily is not a nursing intervention, as it can alter the alignment and stability of the fracture. The clamps should be tightened only by the orthopedic surgeon or a trained technician, and only when necessary. The nurse should inspect the device for any loose or broken parts and report any problems to the surgeon.
So, the correct answer is Choice C, after analysing all choices.
Correct Answer is C
Explanation
The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.
Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.
Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.
Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.
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