After a change-of-shift report, the nurse needs to prioritize care for four clients. Who should the nurse attend to first?

 

Choice A rationale

While it’s true that there are other ways to express intimacy besides intercourse, this response may not address the patient’s specific concern about sexual function following an orchiectomy.

Choice B rationale

This response directly addresses the patient’s concern. The removal of a single testicle does not typically prevent a man from having an erection or enjoying sexual activity.

Choice C rationale

While focusing on recovery is important, this response may not be helpful to the patient. It does not address his concern about sexual function and may make him feel that his concerns are being dismissed.

Choice D rationale

This response may not be helpful to the patient. It does not address his concern about sexual function and may make him feel that his feelings are being minimized.

Choice A.

Choice A rationale

A platelet count of 60,000/mm is significantly lower than the normal range of 150,000 to 400,000/mm. Platelets are crucial for blood clotting, and a low count can increase the risk of bleeding, which is a serious concern for a patient scheduled for a liver biopsy. Therefore, the nurse should report this value to the provider.

Choice B rationale

An ammonia level of 55 mcg/dL falls within the normal range of 10 to 80 mcg/dL1. Ammonia is a byproduct of protein metabolism and is converted to urea in the liver for excretion. Normal levels do not typically pose a concern for liver biopsy.

Choice C rationale

Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver. An AST level of 34 units/L is at the upper limit of the normal range (0 to 34 units/L)1. While it’s

important to monitor, it does not necessarily need to be reported to the provider before a liver biopsy if there are no other signs of liver disease.

Choice D rationale

A bilirubin level of 1.0 mg/dL is within the normal range (0.3 to 1.0 mg/dL)1. Bilirubin is a waste product from the breakdown of red blood cells and is processed by the liver. Normal levels indicate that the liver is functioning properly in this regard.