A client received midazolam 2 mg and morphine sulfate 4 mg for a liver biopsy. After the procedure, the nurse positions the client on the right side and monitors the vital signs. Which is the physiological reason for the nurse's intervention?
Provide pressure over the biopsy site.
Keep the client from aspirating.
Lessen the amount of post procedure pain
Facilitate pulmonary expansion
The Correct Answer is A
A. Provide pressure over the biopsy site:
Positioning the client on the right side after a liver biopsy is aimed at providing pressure over the biopsy site. This pressure helps in promoting hemostasis by compressing the blood vessels at the biopsy site, thus reducing the risk of bleeding or hematoma formation. The liver is located on the right side of the body, so positioning the client on the right side applies pressure directly over the liver, aiding in the prevention of bleeding complications.
B. Keep the client from aspirating:
Positioning the client on the right side after a liver biopsy is not primarily aimed at preventing aspiration. Aspiration precautions are typically implemented during procedures where there is a risk of regurgitation or vomiting, such as during anesthesia induction or recovery, rather than specifically after a liver biopsy.
C. Lessen the amount of post-procedure pain:
While positioning can play a role in managing post-procedure pain, the primary reason for positioning the client on the right side after a liver biopsy is to provide pressure over the biopsy site to promote hemostasis. Pain management strategies such as administering analgesics may be utilized to address any discomfort experienced by the client post-procedure.
D. Facilitate pulmonary expansion:
Positioning the client on the right side after a liver biopsy does not directly facilitate pulmonary expansion. Facilitating pulmonary expansion is typically achieved through interventions such as deep breathing exercises, incentive spirometry, and early ambulation rather than positioning alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Flank pain and profound hypotension:
Correct. Flank pain, often described as a deep, constant, gnawing, or throbbing sensation in the abdomen or back, can be a sign of impending rupture or dissection of an abdominal aortic aneurysm (AAA). Profound hypotension may occur if the AAA ruptures, leading to massive internal bleeding and shock. Prompt recognition of these signs is crucial for early intervention and surgical repair to prevent catastrophic consequences.
B) Acute shortness of breath and chest pain:
Acute shortness of breath and chest pain are more indicative of cardiovascular or pulmonary conditions such as myocardial infarction, pulmonary embolism, or acute coronary syndrome rather than an abdominal aortic aneurysm. While aortic dissection can present with chest pain, it is typically described as severe, tearing, or ripping pain that radiates to the back, not as acute shortness of breath.
C) Absent pedal pulses and darkened toes:
Absent pedal pulses and darkened toes may indicate peripheral vascular disease or critical limb ischemia but are not specific signs of an abdominal aortic aneurysm. While AAA can lead to peripheral ischemia in advanced cases, it is not typically associated with acute changes in pedal pulses or toe discoloration.
D) Tea-colored urine and decreased output:
Tea-colored urine and decreased urine output may indicate acute kidney injury or rhabdomyolysis but are not specific signs of an abdominal aortic aneurysm. While a ruptured AAA can lead to renal ischemia and acute kidney injury due to hypoperfusion, these symptoms are not the primary manifestations of AAA
Correct Answer is C
Explanation
A) Small, skin-colored, pedunculated papules in areas of skin folds and on other areas as skin tags:
This description is more characteristic of acrochordons (skin tags), which are benign skin growths often found in skin folds. Skin tags are typically not associated with acne vulgaris.
B) Hyperpigmented areas that vary in form and color and are slightly elevated from the skin:
This description may be indicative of post-inflammatory hyperpigmentation, which can occur after resolution of acne lesions. However, it does not represent the primary pathological findings observed in acne vulgaris.
C) Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back:
Correct. Acne vulgaris is characterized by hyperactive sebaceous glands, leading to the formation of comedones (blackheads and whiteheads), papules, and pustules. These lesions commonly occur on the face, neck, and upper back due to the high density of sebaceous glands in these areas.
D) Sharply demarcated silvery scaling plaques with underlying redness on the elbows and knees:
This description is more indicative of psoriasis, a chronic autoimmune skin condition characterized by silvery scaling plaques and inflammation. Psoriasis typically affects extensor surfaces such as the elbows and knees, rather than the areas commonly affected by acne vulgaris.
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