A night nurse is preparing a client for a liver biopsy the next morning at 8:00 AM.
Which data is the most important for the nurse to report to the healthcare provider? The client:.

Has had nothing by mouth (NPO) since 2300.

Is having pain in the left lower quadrant, no BM for 24 hours.

Received a dose of clopidogrel at 2200.

Has an allergy.

Answer and Explanation

The Correct Answer is C

The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.

Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.

Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.

Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.

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Correct Answer is A

Explanation

Notify the health care provider to report and anticipate new orders.

This is because an oral temperature of 100.8° F (38.2° C) indicates a fever, which could be a sign of infection or inflammation in an elderly client.

A fever of this magnitude could also cause dehydration, confusion, or seizures in older adults.

Therefore, the nurse should notify the health care provider as soon as possible to determine the cause and treatment of the fever.

Choice B is wrong because covering the client with an additional blanket could increase the body temperature and worsen the fever.

The UAP should not recheck the temperature in two hours, but rather monitor it more frequently and report any changes to the nurse.

Choice C is wrong because charting the temperature on the vital signs sheet and reporting to the new shift coming on is not enough to address the urgency of the situation.

The nurse has a responsibility to act on abnormal findings and communicate them to the health care provider.

Choice D is wrong because assessing the client’s temperature rectally and comparing the results is not necessary and could cause discomfort or injury to the client.

Rectal temperatures are usually higher than oral temperatures by about 0.5° F (0.3° C), so this would not change the interpretation of the fever.

The normal range for oral temperature in adults is 97.6° F to 99.6° F (36.4° C to 37.6° C).

A. Call the Sexual Nurse Examiner. B. Assess vital signs. C. Call her parents to ask for permission to treat. D. Contact Security in case the perpetrator arrives.

Correct Answer is B

Explanation

The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.

Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.

Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.

The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.

Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.

The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.

Calling her parents without her permission may violate her privacy and autonomy.

Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.

The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.

Security measures can be taken later if needed.

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A night nurse is preparing a client for a liver biopsy the next morning at 8:00 AM. Which data is the most important for the nurse to report to the healthcare provider? The client:.

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Naxlex Comprehensive Predictor Exams

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A night nurse is preparing a client for a liver biopsy the next morning at 8:00 AM.
Which data is the most important for the nurse to report to the healthcare provider? The client:.