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    HESI RN Exit Exam IV Proctored Exam

    After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient. During a follow-up visit at the community clinic, the nurse observes that the client has developed jaundice. Which action should the nurse take?

    Explanation & Rationale

    RationaleA. Blood cultures are typically obtained to identify the causative organism of the liver abscess and to monitor the effectiveness of antimicrobial therapy. While repeat blood cultures may be considered if there is concern for ongoing infection or antimicrobial resistance, they may not be the immediate priority in the context of new-onset jaundice.B. Jaundice indicates possible liver dysfunction, which can occur due to various reasons including progression of the liver abscess, obstruction of the bile ducts, or drug-induced liver injury from antimicrobial therapy. Evaluating liver function tests (such as serum bilirubin, liver enzymes) is essential to assess the extent of liver damage and guide further management.C. Increasing protein intake is generally not indicated as the immediate response to jaundice. While adequate nutrition is important, specific dietary adjustments should be based on comprehensive assessment findings and medical recommendations.D. Emergency transport to an inpatient facility may be necessary if the client shows signs of severe complications such as hemodynamic instability, worsening symptoms, or acute liver failure. However, this decision should be based on a thorough assessment of the client's condition and the availability of resources at the community clinic.

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