Nokea
The client has had a liver biopsy. Which postprocedure intervention should the nurse implement?
- A. Instruct the client to void immediately.
- B. Keep the client NPO for eight (8) hours.
- C. Place the client on the right side.
- D. Monitor blood urea nitrogen (BUN) and creatinine level.
Correct Answer: C
Rationale: Placing the client on the right side applies pressure to the biopsy site, reducing bleeding risk. Voiding, NPO status, and BUN/creatinine are not specific to liver biopsy care.
You may also like to solve these questions
A child with appendicitis is scheduled for surgery this evening. The nurse enters the room and sees the child's mother starting to place hot, wet washcloths on her daughter's abdomen so that 'she will feel better.' The nurse explains that this action is contraindicated because heat:
- A. can cause the appendix to rupture and cause peritonitis.
- B. can mask symptoms of acute appendicitis.
- C. will increase peristalsis throughout the abdomen.
- D. will arrest progression of the disease.
Correct Answer: A
Rationale: Heat can increase inflammation and blood flow, risking appendix rupture and peritonitis in appendicitis.
The nurse is irrigating the client's colostomy when the client complains of cramping. What is the most appropriate initial action by the nurse?
- A. Increase the flow of solution
- B. Ask the client to turn to the other side
- C. Pinch the tubing to interrupt the flow of the solution
- D. Remove the tube from the colostomy
Correct Answer: C
Rationale: Pinching the tubing stops the flow, relieving cramping caused by rapid fluid instillation during colostomy irrigation.
While reviewing the client’s medical records, the nurse notes the diagnosis of biliary colic. Considering this diagnosis, which additional sign will the nurse most likely find in the client’s medical record?
- A. Bloody diarrhea
- B. Heartburn and regurgitation
- C. Abdominal distention
- D. Severe abdominal pain
Correct Answer: D
Rationale: A. Diarrhea is not related to biliary colic. B. Heartburn and regurgitation are not related to biliary colic. C. Abdominal distention is not related to biliary colic. D. Biliary colic is the term used for the severe pain that is caused by a gallstone lodged in the cystic or common bile duct and/or traveling through the ducts. The presence of the stone causes the duct to spasm, causing severe abdominal pain.
The client with a new colostomy is being discharged. Which statement made by the client indicates the need for further teaching?
- A. If I notice any skin breakdown, I will call the HCP.
- B. I should drink only liquids until the colostomy starts to work.
- C. I should not take a tub bath until the HCP okays it.
- D. I should not drive or lift more than five (5) pounds.
Correct Answer: B
Rationale: A liquid-only diet is unnecessary; a regular diet can be resumed as tolerated unless otherwise specified, as colostomies begin functioning soon after surgery. The other statements reflect correct colostomy care.
The nurse is working in an outpatient clinic. Which client is most likely to have a diagnosis of diverticulosis?
- A. A 60-year-old male with a sedentary lifestyle.
- B. A 72-year-old female with multiple childbirths.
- C. A 63-year-old female with hemorrhoids.
- D. A 40-year-old male with a family history of diverticulosis.
Correct Answer: A
Rationale: Diverticulosis is more common in older adults with sedentary lifestyles, which contribute to constipation and increased colonic pressure. Childbirth, hemorrhoids, and family history are less direct risk factors.