Questions: 1. The nurse notes that the client's total bilirubin is 1.0 mg / dL. Which action by the nurse is correct? 1. Assess the client's sclerae for evidence of jaundice. 2. Check the client's stool for presence of occult blood. 3. Record the results as normal. 4. Test the client's urine for blood. 2. After a liver biopsy on the client with cirrhosis, which nursing intervention is most appropriate to add to the plan of care? 1. Ambulate the client twice each shift. 2. Elevate the client's legs on two pillows. 3. Keep the client in high Fowler position. 4. Position the client on their right side. 3. Which action by the nurse best reduces the risk of transmitting the virus for a client diagnosed with HAV? 1. The nurse puts on a mask and gown when providing direct care. 2. The nurse maintains the client in a private room at all times. 3. The nurse performs vigorous hand washing after leaving the room. 4. The nurse wears gloves when entering the client's room.

1. The nurse notes that the client's total bilirubin is 1.0 mg / dL. Which action by the nurse is correct?
   1. Assess the client's sclerae for evidence of jaundice.
   2. Check the client's stool for presence of occult blood.
   3. Record the results as normal.
   4. Test the client's urine for blood.
2. After a liver biopsy on the client with cirrhosis, which nursing intervention is most appropriate to add to the plan of care?
   1. Ambulate the client twice each shift.
   2. Elevate the client's legs on two pillows.
   3. Keep the client in high Fowler position.
   4. Position the client on their right side.
3. Which action by the nurse best reduces the risk of transmitting the virus for a client diagnosed with HAV?
   1. The nurse puts on a mask and gown when providing direct care.
   2. The nurse maintains the client in a private room at all times.
   3. The nurse performs vigorous hand washing after leaving the room.
   4. The nurse wears gloves when entering the client's room.
Transcript text: 1. The nurse notes that the client's total bilirubin is $1.0 \mathrm{mg} / \mathrm{dL}$. Which action by the nurse is correct? 1. Assess the client's sclerae for evidence of jaundice. 2. Check the client's stool for presence of occult blood. 3. Record the results as normal. 4. Test the client's urine for blood. 2. After a liver biopsy on the client with cirrhosis, which nursing intervention is most appropriate to add to the plan of care? 1. Ambulate the client twice each shift. 2. Elevate the client's legs on two pillows. 3. Keep the client in high Fowler position. 4. Position the client on their right side. 3. Which action by the nurse best reduces the risk of transmitting the virus for a client diagnosed with HAV? 1. The nurse puts on a mask and gown when providing direct care. 2. The nurse maintains the client in a private room at all times. 3. The nurse performs vigorous hand washing after leaving the room. 4. The nurse wears gloves when entering the client's room.
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Solution

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  1. The answer is the third one: Record the results as normal.

    Explanation:

    • Total bilirubin levels in the blood are typically considered normal when they are between 0.1 and 1.2 mg/dL. A level of 1.0 mg/dL falls within this normal range, so the nurse should record the results as normal.
    • Assessing the client's sclerae for jaundice (option 1) is unnecessary because the bilirubin level is normal.
    • Checking the client's stool for occult blood (option 2) and testing the client's urine for blood (option 4) are unrelated to the bilirubin level.
  2. The answer is the fourth one: Position the client on their right side.

    Explanation:

    • After a liver biopsy, it is important to apply pressure to the biopsy site to prevent bleeding. Positioning the client on their right side helps apply pressure to the liver, which is located on the right side of the body.
    • Ambulating the client (option 1) and elevating the legs (option 2) are not directly related to post-biopsy care.
    • Keeping the client in high Fowler position (option 3) does not help in applying pressure to the biopsy site.
  3. The answer is the third one: The nurse performs vigorous hand washing after leaving the room.

    Explanation:

    • Hepatitis A virus (HAV) is primarily transmitted via the fecal-oral route. Proper hand hygiene is crucial in preventing the spread of the virus.
    • Wearing a mask and gown (option 1) is not necessary for HAV, as it is not airborne.
    • Maintaining the client in a private room (option 2) is not specifically required for HAV, though it may be done for other reasons.
    • Wearing gloves (option 4) is important, but hand washing is the most effective measure to prevent transmission.
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