The nurse is caring for a client who returned from a liver biopsy 30 minutes ago. The client presses the call light and upon arrival in the room the client is pale and complaining of feeling as if they might pass out what of the following is the nurses priority action?

Notify the health care provider

Administer a 1-liter bolus of normal saline

Inspect the biopsy site dressing

Position the client on the right side

Answer and Explanation

The Correct Answer is C

A. Notify the health care provider: While notifying the provider is important, assessing the client comes first to determine if there is active bleeding.

B. Administer a 1-liter bolus of normal saline: Fluid resuscitation is used for shock, but the cause of symptoms must be assessed first.

C. Inspect the biopsy site dressing: The most concerning complication after a liver biopsy is internal bleeding, as the liver is highly vascular. Pallor and near-syncope may indicate hemorrhage. The priority action is to assess the biopsy site for bleeding before taking further action.

D. Position the client on the right side: Clients are typically positioned on the right side after a liver biopsy to apply pressure and reduce bleeding risk, but since the client is already experiencing symptoms of hypovolemia, assessment and intervention for potential hemorrhage take precedence.

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Correct Answer is A

Explanation

A. "I ate shellfish about 2 weeks ago at a local restaurant." Hepatitis A is transmitted via the fecal-oral route, often through contaminated food or water, including raw or undercooked shellfish. The incubation period is 2–6 weeks, making this history relevant.

B. "I have had unprotected sex with multiple partners." While sexual transmission is possible, hepatitis B and C are more commonly spread this way. Hepatitis A is not primarily a sexually transmitted infection.

C. "I had a blood transfusion in the 80s after a major car accident." Hepatitis C, not hepatitis A, is transmitted through blood products. Before 1992, blood transfusions carried a higher risk of hepatitis C infection.

D. "I am a recovered addict of 10 years." Injection drug use is a major risk factor for hepatitis B and C, but not hepatitis A, which is spread through ingestion of contaminated food or water.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The client's ammonia level is critically elevated (250 mcg/dL), which can lead to altered mental status, confusion, and lethargy, consistent with hepatic encephalopathy. In cirrhosis, the liver loses its ability to detoxify ammonia, leading to its accumulation in the bloodstream. This excess ammonia crosses the blood-brain barrier, impairing neuronal function and causing hepatic encephalopathy.

Incorrect answers:

DKA is characterized by high blood glucose (>250 mg/dL), metabolic acidosis, and ketonemia. This client has a moderate glucose elevation (148 mg/dL) but no signs of acidosis, Kussmaul respirations, or ketonuria.

Dehydration: While dehydration can contribute to mental status changes, severe hyperammonemia is a direct cause of hepatic encephalopathy. The client's crackles in the lungs and peripheral edema suggest fluid retention, not dehydration.

Acute kidney disease presents with rising creatinine levels, oliguria, and electrolyte imbalances. This client’s creatinine level is normal, ruling out acute kidney disease.

Malnutrition is characterized by low albumin, muscle wasting, and weight loss, but this client's elevated glucose is more likely due to diabetes mellitus rather than malnutrition.

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The nurse is caring for a client who returned from a liver biopsy 30 minutes ago. The client presses the call light and upon arrival in the room the client is pale and complaining of feeling as if they might pass out what of the following is the nurses priority action?

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Naxlex Comprehensive Predictor Exams

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

Correct Answer is A

Explanation

A nurse is caring for a client in the emergency department (ED). Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is exhibiting manifestations of dropdown due to the client’s dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

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