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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.
B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).
C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.
D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.
Correct Answer is B
Explanation
A. Respiratory acidosis: Respiratory acidosis would present with a low pH (below 7.35) and a high PaCO2 (above 45 mmHg).
B. Respiratory alkalosis: This ABG shows a high pH (7.51), low PaCO2 (32 mmHg), and normal HCO3- (26 mEq/L), indicating respiratory alkalosis, typically due to hyperventilation.
C. Metabolic acidosis: Metabolic acidosis would present with a low pH and low HCO3-, but in this case, the HCO3- is normal.
D. Metabolic alkalosis: Metabolic alkalosis would show a high pH and high HCO3-, but the HCO3- in this ABG is normal.
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