A patient is scheduled for a liver biopsy.
Which laboratory result would be of most concern to the nurse?
Serum ammonia level of 56 mcg N/dL
Hemoglobin of 11 g/dL
White blood cell count of 14.2 x 103/uL
Prothrombin time of 32 seconds
The Correct Answer is D
Choice A rationale
While an elevated serum ammonia level can indicate liver dysfunction, it is not typically a contraindication for liver biopsy. Ammonia is a byproduct of protein metabolism and is normally converted into urea by the liver, which is then excreted in the urine. Elevated levels can occur in liver disease, but they are not typically a direct concern in the context of a liver biopsy.
Choice B rationale
A hemoglobin level of 11 g/dL is slightly low, but it is not typically a contraindication for a liver biopsy. Hemoglobin is the protein in red blood cells that carries oxygen. While a low hemoglobin level can indicate anemia, it would not typically prevent a patient from undergoing a liver biopsy.
Choice C rationale
A white blood cell count of 14.2 x 103/uL is slightly elevated, indicating a possible infection or inflammation. However, this would not typically be a contraindication for a liver biopsy.
Choice D rationale
A prothrombin time of 32 seconds is significantly prolonged, indicating a potential problem with blood clotting. This would be a major concern for a nurse caring for a patient scheduled for a liver biopsy, as the procedure involves inserting a needle into the liver and could lead to bleeding. Patients with a prolonged prothrombin time are at an increased risk of bleeding complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While chronic exposure to UV rays can cause skin dryness, it does not decrease the water content of the skin20. Skin dryness is more of a symptom rather than a risk factor for skin cancer20.
Choice B rationale
Chronic exposure to UV rays can cause an error in the skin’s genetic code20. This can lead to the development of skin cancer, as the damaged DNA can lead to uncontrolled cell growth20.
Choice C rationale
Increased blood flow to the skin is not a direct result of chronic exposure to UV rays20. While UV rays can cause skin redness and inflammation, these are not directly linked to an increased risk of skin cancer20.
Choice D rationale
Chronic exposure to UV rays does not cause degeneration of elastic fibers in skin tissue20. While UV rays can cause skin aging and wrinkles, these are not direct risk factors for skin cancer20. Diabetic retinopathyDiabetic retinopathy Explore
Correct Answer is D
Explanation
Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale
Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.
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