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 C
Explanation
Acne vulgaris is a common skin condition characterized by various types of lesions, including comedones, papules, and pustules, primarily affecting areas with a high density of sebaceous glands, such as the face, neck, chest, and upper back. Here's why option C is the correct choice:
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 or skin tags, which are benign skin growths commonly found in areas of friction or skin folds. Skin tags are not typically associated with acne vulgaris.
B) Hyperpigmented areas that vary in form and color and are slightly elevated from the skin:
This description suggests post-inflammatory hyperpigmentation, which can occur after resolution of inflammatory lesions in acne vulgaris. However, it does not capture the primary pathological findings observed in active acne lesions.
C) Hyperactive sebaceous areas forming comedones, papules, pustules on the face, neck, and upper back:
Correct. Acne vulgaris is characterized by the formation of various lesions, including comedones (open and closed), papules, and pustules, resulting from the obstruction of hair follicles and overactivity of sebaceous glands. These lesions typically appear on areas with a high density of sebaceous glands, such as the face, neck, chest, and upper back.
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 sharply demarcated, raised, silvery scaling plaques commonly affecting extensor surfaces such as the elbows and knees. Psoriasis lesions are distinct from those seen in acne vulgaris.
Correct Answer is A
Explanation
A) Deficiency of factors VIII or IX.
Hemophilia is a genetic disorder characterized by deficient or defective clotting factors, specifically factors VIII (hemophilia A) or IX (hemophilia B). These clotting factors are essential for the formation of stable blood clots. Therefore, if hemophilia is present, the deficiency of factors VIII or IX can lead to impaired clot formation and prolonged bleeding.
B) Diminished amount of vitamin K:
Vitamin K deficiency can lead to impaired blood clotting due to inadequate synthesis of clotting factors in the liver. However, hemophilia is specifically associated with deficiencies in factors VIII or IX, not vitamin K.
C) Decreased amount of platelets:
Platelets play a crucial role in primary hemostasis and initial platelet plug formation at the site of vascular injury. While decreased platelet count or dysfunction can lead to bleeding disorders such as thrombocytopenia or platelet function disorders, hemophilia specifically involves deficiencies in clotting factors, not platelets.
D) Missing factors V and VII:
Factor V and VII are other clotting factors involved in the coagulation cascade, but they are not deficient in hemophilia. Hemophilia is specifically characterized by deficiencies in factors VIII (hemophilia A) or IX (hemophilia B).
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