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The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
- A. Tolerance for pain
- B. Allergy to iodine or shellfish
- C. History of nausea and vomiting
- D. Ability to lie still and hold the breath
Correct Answer: D
Rationale: A liver biopsy is an invasive procedure that involves inserting a needle into the liver to obtain a tissue sample. To ensure client safety, the nurse must assess the client's ability to lie still and hold their breath during the procedure, as movement or breathing can cause complications such as bleeding or injury to surrounding organs. Assessing pain tolerance, allergies to iodine or shellfish, or a history of nausea and vomiting is not directly related to the safety of the liver biopsy procedure.
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The nurse is caring for a client scheduled to undergo a renal biopsy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
- A. Prothrombin time: 15 seconds
- B. Potassium: 3.8 mEq/L (3.8 mmol/L)
- C. Serum creatinine: 1.2 mg/dL (106 mcmol/L)
- D. Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L)
Correct Answer: A
Rationale: Postprocedure hemorrhage is a complication after renal biopsy. Because of this, prothrombin time is assessed before the procedure. The normal prothrombin time range is 11 to 12.5 seconds. The nurse ensures that these results are available and reports abnormalities promptly. Options 2, 3, and 4 identify normal values. The normal potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L); the normal serum creatinine is 0.5 to 1.2 mg/dL (44 to 106 mcmol/L); and the normal BUN is 10-20 mg/dL (3.6-7.1 mmol/L).
The nurse is providing care for a client who has just experienced a liver biopsy performed at the bedside. Which position should the nurse place the client in after the biopsy?
- A. Supine with the head elevated on one pillow
- B. Semi-Fowler's with two pillows under the legs
- C. Left side-lying with a small pillow under the puncture site
- D. Right side-lying with a folded towel under the puncture site
Correct Answer: D
Rationale: The liver is located on the right side of the body. After a liver biopsy, the nurse positions the client on the right side with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the abdominal wall at the biopsy site to tamponade bleeding from the puncture site.
A client prescribed prazosin hydrochloride asks the nurse why the first dose must be taken at bedtime. Which response by the nurse is based on the understanding of the first dose use of prazosin hydrochloride?
- A. Treatment with prazosin hydrochloride results in drowsiness.
- B. Treatment with prazosin hydrochloride can cause dependent edema.
- C. Prazosin hydrochloride should be taken when the stomach is empty.
- D. Treatment with prazosin hydrochloride can cause dizziness or possible syncope.
Correct Answer: D
Rationale: Prazosin is an alpha-adrenergic blocking agent. 'First-dose hypotensive reaction' may occur during early therapy, which is characterized by dizziness, lightheadedness, and possible loss of consciousness. The occurrence of these effects is better tolerated if the client is in bed. This also can occur when the dosage is increased. This effect usually disappears with continued use or the dosage is decreased.
The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube?
- A. Pulling the tube back slightly
- B. Instructing the client to breathe slowly
- C. Continuing to advance the tube to the desired distance
- D. Checking the back of the pharynx using a tongue blade and flashlight
Correct Answer: C
Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. The nurse should check the back of the pharynx using a tongue blade and flashlight to check for coiling and then pull the tube back slightly to prevent entrance into the larynx. Slow breathing helps the client relax to reduce the gag response.
After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands?
- A. Fever
- B. Neck pain
- C. Hoarseness
- D. Tingling around the mouth
Correct Answer: D
Rationale: The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Fever may be expected in the immediate postoperative period but is not an indication of damage to the parathyroid glands. However, if a fever persists the primary health care provider is notified. Neck pain and hoarseness are expected findings postoperatively.