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.
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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Related Questions
Correct Answer is D
Explanation
A) Lactulose is used to treat hepatic encephalopathy and is not prescribed to reduce the risk of bleeding from esophageal varices.
B) Omeprazole is a proton pump inhibitor used to reduce stomach acid production and treat conditions such as peptic ulcers and gastroesophageal reflux disease (GERD). While it may be prescribed to manage gastritis or peptic ulcers, it is not primarily used to reduce the risk of bleeding from esophageal varices.
C) Furosemide is a diuretic used to manage fluid retention and ascites in clients with liver cirrhosis. It is not prescribed to reduce the risk of bleeding from esophageal varices.
D) Propranolol is a beta-blocker commonly used to reduce the risk of bleeding from esophageal varices in clients with liver cirrhosis. Propranolol helps decrease portal hypertension by reducing the pressure in the portal vein, thereby reducing the likelihood of variceal rupture and bleeding.
Correct Answer is D
Explanation
A) This statement is incorrect. Chronic hepatitis C infection is a significant risk factor for liver cirrhosis, and individuals with this infection require regular monitoring and appropriate medical management to prevent or delay the progression of cirrhosis.
B) While hepatitis D co-infection can worsen the course of chronic hepatitis B or C infection, it does not diminish the significance of hepatitis C infection as a risk factor for liver cirrhosis.
C) While chronic hepatitis B infection is also a known risk factor for liver cirrhosis, the client's history of hepatitis C infection is more relevant to the risk of developing cirrhosis in this case.
D) Chronic hepatitis C infection is a well-established risk factor for liver cirrhosis. The hepatitis C virus causes persistent inflammation in the liver, leading to liver cell damage and scarring (fibrosis). Over time, this fibrosis can progress to cirrhosis, which is the advanced stage of liver damage.
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