A patient has just undergone a percutaneous liver biopsy. Which of the following are included in the post-procedure assessment? (select all that apply)
instruct the patient to lie on the Left side
assess the patient's vital signs
assess the dressing over the puncture site
assess for signs/symptoms of a pneumothorax
Correct Answer : B,C,D
A. Instruct the patient to lie on the Left side: The patient should lie on their right side (the biopsy side) to apply pressure and prevent bleeding.
B. Assess the patient's vital signs: Monitoring vital signs is crucial to detect signs of bleeding, hypovolemia, or shock.
C. Assess the dressing over the puncture site: Checking for bleeding or hematoma formation at the puncture site is important to detect complications.
D. Assess for signs/symptoms of a pneumothorax: A pneumothorax is a possible complication of liver biopsy, especially if the biopsy needle punctures the lung.
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Related Questions
Correct Answer is A
Explanation
A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.
B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.
C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.
D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.
Correct Answer is D
Explanation
A. Administer a stat fluid challenge: This might temporarily improve cardiac output in tamponade, but it is not the primary intervention. The fluid challenge may be used as a temporary measure, but it does not address the underlying cause.
B. Place the patient in a prone position: This is incorrect and could worsen the patient's condition. The patient should be in a semi-recumbent position to decrease venous return and reduce pressure on the heart.
C. Draw a stat CBC: A CBC is not relevant to the immediate management of cardiac tamponade and does not address the urgent need to relieve the pressure on the heart.
D. Perform a stat pericardiocentesis: Pericardiocentesis is the definitive treatment for cardiac tamponade, as it removes the fluid from the pericardial space, relieving the pressure on the heart and allowing it to function properly.
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