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 D

Explanation

Independent. An independent nursing intervention is an action that a nurse can perform by themselves, without any management from a doctor or another discipline.

Taking the client’s temperature again is an example of an independent nursing intervention because it does not require a physician’s order or collaboration with other health care professionals.

Choice A is wrong because an interdependent nursing intervention is an action that requires collaboration or consultation with other health care professionals.

Taking the client’s temperature again does not involve working with other disciplines.

Choice B is wrong because a dependent nursing intervention is an action that requires an order from a physician or another health care provider.

Taking the client’s temperature again does not require a physician’s order.

Choice C is wrong because a collaborative nursing intervention is an action that involves working with other health care professionals to provide patient care.

Taking the client’s temperature again does not require collaboration with other disciplines.

A. Visual inspection of skin for placement. B. Positioning for proper body alignment. C. Assess the need for restraints placement. D. Review facility policy before usage.

Correct Answer is C

Explanation

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

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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:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A health care provider has ordered vital signs every 4 hours. The client’s 8:00 AM temperature was 99° F (37.2° C). At 10 AM, the client reported chills. A nurse takes the client’s temperature again. Which type of nursing action does this exemplify?

Correct Answer is D

Explanation

Which nursing intervention should be performed before applying client restraints?

Correct Answer is C

Explanation

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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:.