A client with suspected liver cirrhosis undergoes a liver biopsy. Which nursing action is essential following the procedure?

Encouraging the client to lie on the right side.

Administering pain medication as needed.

Monitoring vital signs every 4 hours.

Instructing the client to maintain a supine position for 12 hours.

Answer and Explanation

The Correct Answer is A

A. Encouraging the client to lie on the right side after a liver biopsy is essential because this position helps to apply pressure to the biopsy site, reducing the risk of bleeding.
B. While administering pain medication may be necessary, it is not the primary nursing action following a liver biopsy compared to ensuring hemostasis and preventing complications.
C. Monitoring vital signs is important, but in this case, vital signs should be checked more frequently than every 4 hours to assess for complications like bleeding. Initial monitoring is typically every 15 minutes for the first hour and then every 30 minutes to hourly based on facility protocols.
D. Although maintaining a supine position is typically advised, the focus should be on the right side position to ensure proper hemostasis following the biopsy procedure.

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Correct Answer is C

Explanation

A) This statement is incorrect. Even moderate alcohol intake can be harmful to a client with liver cirrhosis. Alcohol should be completely avoided to prevent exacerbation of liver damage.

B) This statement is incorrect. The client should not resume their previous alcohol consumption habits. Continued alcohol consumption can lead to further liver damage and complications.

C) For a client with liver cirrhosis, alcohol consumption should be completely avoided. Alcohol is a significant contributor to liver damage and can worsen the condition, leading to further complications. Abstinence from alcohol is crucial to prevent further liver injury and improve the client's overall prognosis.

D) This statement is incorrect. The client should not consume any type of alcoholic beverage. All forms of alcohol can be harmful to the liver, and complete abstinence is necessary for individuals with liver cirrhosis.

A. Hematemesis B. Ascites C. Splenomegaly D. Varices

Correct Answer is D

Explanation

A) Hematemesis refers to vomiting of blood and is a symptom that can occur as a result of bleeding from esophageal varices or other gastrointestinal sources.

B) Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. It is not related to the presence of visible distended veins on the abdomen and chest.

C) Splenomegaly is the enlargement of the spleen and is not related to the finding of visible distended veins.

D) Varices are dilated and tortuous veins that can develop in various locations, including the esophagus (esophageal varices) and the abdomen and chest wall (caput medusae). In liver cirrhosis, portal hypertension causes increased pressure in the portal vein, leading to the development of these enlarged veins. Esophageal varices can be life-threatening if they rupture and cause severe bleeding.

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A client with suspected liver cirrhosis undergoes a liver biopsy. Which nursing action is essential following the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client with liver cirrhosis. Which statement by the nurse is appropriate regarding alcohol consumption?

Correct Answer is C

Explanation

A client with liver cirrhosis is found to have visible distended veins on the abdomen and chest. Which term should the nurse use to document this finding?

Correct Answer is D

Explanation

A nurse is assessing a client with liver cirrhosis and observes that the client has altered mental status and confusion. Which action should the nurse take first?

A client with liver cirrhosis complains of difficulty sleeping at night due to frequent awakenings caused by shortness of breath. Which complication should the nurse suspect as the most likely cause of the client's symptom?

A client with liver cirrhosis has developed ascites. Which nursing intervention is a priority for managing this complication?

A client with liver cirrhosis is at risk of developing esophageal varices. Which nursing intervention is essential in the care of this client?

A client with liver cirrhosis is admitted to the hospital with hepatic encephalopathy. Which nursing intervention is essential in the care of this client?

A client with liver cirrhosis is at risk of bleeding due to decreased synthesis of clotting factors. Which nursing intervention is essential in preventing bleeding episodes?

A client with liver cirrhosis is at risk of developing esophageal varices. Which medication should the nurse expect to be prescribed to reduce the risk of bleeding from these varices?

A client with liver cirrhosis is experiencing episodes of hepatic encephalopathy. Which medication should the nurse anticipate administering to help reduce ammonia levels in the blood?