A triage nurse in the emergency department assesses a client who complains of 7/10 abdominal pain and states. "I had a temperature of 103.9 Fat home." Which action should the nurse take first?

Give acetaminophen per agency protocol

Assess the patient's current vital signs.

Ask the client to provide a clean-catch urine for urinalysis.

Tell the client that it will be 1 to 2 hours before seeing a health care provider

Answer and Explanation

The Correct Answer is B

Rationale:

A. While fever reduction can improve patient comfort, administering acetaminophen before assessing current vital signs is inappropriate. Fever is a clinical sign that may indicate a serious infection or sepsis. Giving medication first could mask important symptoms such as elevated temperature or tachycardia, potentially delaying recognition and treatment of a life-threatening condition.

B. Triage nurses must follow the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure) and prioritize immediate assessment of hemodynamic stability. The client reports a high fever of 103.9°F at home and moderate abdominal pain rated 7/10, which may indicate a serious infection such as pyelonephritis, appendicitis, or sepsis. Assessing current vital signs—including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation—provides crucial information to identify acute instability and determine the urgency of care. Early recognition and prioritization of high-acuity patients are critical in the emergency setting.

C. Although urinalysis may be necessary to evaluate for a urinary tract infection or other causes of fever and abdominal pain, collecting diagnostic specimens is secondary to assessing the client’s immediate physiological status. If the client is unstable, diagnostic tests can be delayed until after vital signs are assessed and stabilization is initiated.

D. Providing this information without first assessing vital signs is unsafe. The client may have a potentially life-threatening condition that requires immediate intervention. Delaying assessment could result in clinical deterioration and poor outcomes.

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Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. In advanced cirrhosis, the liver’s synthetic function is impaired, leading to decreased production of albumin. Low albumin contributes to ascites, peripheral edema, and decreased oncotic pressure. A value of 7.2 g/dL is well above the normal range and is inconsistent with cirrhosis, making this an unlikely finding in this disease process.

B. Thrombocytopenia is a common finding in cirrhosis due to multiple mechanisms. Portal hypertension causes splenic enlargement (splenomegaly) and sequestration of platelets, while impaired liver function decreases thrombopoietin production, reducing platelet formation. A platelet count of 75,000 cells/mm³ reflects significant reduction and is consistent with advanced liver disease.

C. Amylase is an enzyme produced primarily by the pancreas and salivary glands. While levels may be slightly elevated in pancreatic disorders, it is not a specific or consistent marker of liver dysfunction. A value of 200 units/L is within or near the normal range and does not correlate with cirrhosis.

D. Elevated ammonia occurs in cirrhosis because the damaged liver cannot efficiently convert ammonia to urea, leading to accumulation in the blood. High ammonia levels are associated with hepatic encephalopathy, causing confusion, altered mental status, and other neurologic symptoms. A value of 96 mcg/dL is above the normal range and consistent with advanced liver disease.

E. The liver synthesizes most clotting factors, so impaired hepatic function in cirrhosis leads to coagulopathy, reflected as a prolonged prothrombin time (PT). A PT of 22 seconds indicates significant impairment of the clotting cascade, which is a common complication of advanced cirrhosis.

A. Obtains the client's vital signs every hour. B. Positions the client onto the right side. C. Ambulates the client 1-hour post-procedure. D. Encourages the client to cough and deep-breathe hourly.

Correct Answer is B

Explanation

Rationale:

A. After a liver biopsy, the risk of complications such as hemorrhage is highest in the first few hours. Therefore, vital signs should be assessed every 15 minutes for the first hour, every 30 minutes for the second hour, and then hourly if stable. Waiting an entire hour between assessments is inadequate and could delay detection of hypotension, tachycardia, or other early signs of internal bleeding.

B. After a liver biopsy, it is standard practice to position the client on their right side with a pillow or small cushion under the puncture site. This applies direct pressure to the liver to help achieve hemostasis, reducing the risk of post-procedural bleeding or hematoma formation. Maintaining this position for at least 2 to 4 hours is recommended. This action reflects a clear understanding of post-procedural care and the priority of protecting the biopsy site.

C. Clients are typically instructed to remain on bed rest for 2 to 6 hours, depending on provider protocol. Early ambulation increases intra-abdominal pressure and raises the risk of bleeding or dislodging the clot at the biopsy site, potentially leading to hemorrhage, hypotension, and pain.

D. While coughing and deep breathing are important for preventing pulmonary complications like atelectasis, they should be avoided immediately after a liver biopsy. Forceful coughing or deep breathing increases intra-abdominal pressure, which can disrupt the liver puncture site, cause bleeding, and lead to pain or hematoma formation.

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A triage nurse in the emergency department assesses a client who complains of 7/10 abdominal pain and states. "I had a temperature of 103.9 Fat home." Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

The nurse assesses a client admitted with advanced cirrhosis of the liver. Which laboratory results are consistent with the disease process? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is B

Explanation

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