Nokea
Which nursing intervention should be completed immediately after the health care provider has performed a needle liver biopsy?
- A. Assisting to ambulate for the bathroom
- B. Keeping the patient on the right side for a minimum of 2 hours
- C. Taking vital signs every 4 hours
- D. Keeping the patient on the left side for a minimum of 4 hours
Correct Answer: B
Rationale: Keep the patient lying on the right side with a rolled towel against the puncture site for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours.
You may also like to solve these questions
Viral hepatitis may be treated at home. Which should be taught to the patient's family?
- A. Clothes should be laundered separately with hot water.
- B. Personal items and drinking glasses should not be shared.
- C. Articles soiled with feces do not require extra care.
- D. Hands need to be thoroughly washed after toileting.
- E. Contaminated items may be disposed of with regular trash.
Correct Answer: A,B,D
Rationale: For the patient with viral hepatitis being cared for in the home, the family needs to be taught necessary precautions. Clothes should be laundered separately with hot water. Personal items used by the patient should not be shared. Articles soiled with feces must be disinfected. Any contaminated items should be disposed of properly.
Which will the nurse point out as a significant advantage of the laparoscopic cholecystectomy?
- A. Slightly more invasive, but there is less pain
- B. Can be performed on all patients of any age
- C. Can be performed even when there are large stones present in the bile duct
- D. Less invasive procedure
Correct Answer: D
Rationale: The laparoscopic cholecystectomy is less invasive and causes less pain and a quick recovery. If there are large stones present, a sphincterotomy is done before the laparoscopic cholecystectomy. Persons with bleeding tendencies, pathologic conditions of the abdomen, stones in the bile duct, and extensive adhesions are not good candidates.
Which factors may increase a patient's risk of developing cancer of the pancreas?
- A. Diet high in carbohydrates and dairy products
- B. Cardiovascular disease and glaucoma
- C. Tea and cola consumption
- D. Cigarette smoking and having diabetes mellitus
Correct Answer: D
Rationale: The cause of cancer of the pancreas is unknown, but it is diagnosed more often in cigarette smokers, people exposed to chemical carcinogens, and people with diabetes mellitus and pancreatitis.
The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as how many hours after the onset of pancreatic disease?
- A. 2 hours
- B. 8 hours
- C. 24 hours
- D. 36 hours
Correct Answer: A
Rationale: An increase in the serum amylase can be detected as early as 2 hours after the onset of pancreatic disease. In simple acute pancreatitis, the level returns to normal in about 36 hours. In chronic disease, it remains elevated.
When caring for an extremely jaundiced patient with cirrhosis, which does the nurse expect to see included in the plan of care?
- A. Encouraging consumption of a high-fat diet
- B. Skin care to relieve pruritus
- C. Offering foods rich in fat-soluble vitamins
- D. Meticulous foot care
Correct Answer: B
Rationale: Jaundice causes pruritus and can lead to skin lesions and pressure injury.