After undergoing a liver biopsy, which post-procedure assessment is the nurse's priority?

Check vital signs for signs of hypovolemic shock

Assess for abdominal distension and pain

Monitor for signs of infection at the biopsy site

Evaluate the client's level of consciousness

Answer and Explanation

The Correct Answer is A

Rationale:

A. The most serious and potentially life-threatening complication after a liver biopsy is hemorrhage. Bleeding may occur either at the puncture site or internally within the abdominal cavity. Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, and cool, clammy skin. Monitoring vital signs frequently—typically every 15 minutes for the first hour and then at progressively longer intervals if stable—allows the nurse to detect bleeding early and intervene promptly. Early recognition is essential because internal bleeding may not be immediately visible, and delays can result in rapid deterioration and death. Vital signs are therefore the priority assessment immediately post-procedure.

B. This is incorrect as the primary focus, though it remains an important secondary assessment. Abdominal pain, tenderness, or distension may indicate bleeding or bile leakage, but vital signs usually change before these physical findings become apparent. Relying solely on subjective symptoms could delay recognition of serious complications.

C. Infection is a potential late complication of liver biopsy, typically developing days after the procedure. While monitoring the site for redness, swelling, or drainage is part of ongoing post-procedure care, it is not the immediate priority compared to detecting life-threatening hemorrhage.

D. This is incorrect as the primary immediate assessment. Changes in mental status may indicate severe hypovolemia, hypoxia, or hepatic encephalopathy, but they are less sensitive and later indicators than vital sign changes. By the time significant mental status changes occur, the client may already be in advanced shock, making early vital sign monitoring more critical.

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Correct Answer is C

Explanation

Rationale:

A. Obtaining a type and crossmatch is necessary for blood transfusion in variceal bleeding, but this is not the immediate first action. Stabilizing the airway takes precedence over preparing for transfusion.

B. Inserting two large-bore IV lines is important for rapid fluid or blood replacement, but it comes after ensuring the airway is clear and the client can oxygenate effectively. IV access alone does not prevent hypoxia.

C. Suctioning the airway is the first priority. Clients with variceal bleeding are at risk for vomiting large amounts of blood, which can obstruct the airway and cause aspiration or hypoxemia. According to the ABC (Airway, Breathing, Circulation) priority framework, maintaining a patent airway is always the first action in emergencies.

D. Preparing the client for endoscopy is essential for definitive treatment of variceal bleeding, but this is not the immediate priority. The client must first be stabilized—airway maintained, breathing supported, and circulation ensured—before diagnostic or therapeutic procedures.

A. The dressing at the paracentesis site has 1 cm of clear drainage. B. The blood pressure is 96/48 mmHg, and the heart rate is 115 beats/min. C. The client starts crying and says she can't go on with treatment much longer. D. The client weighs less post procedure.

Correct Answer is B

Explanation

Rationale:

A. After a paracentesis, it is normal for a small amount of clear serous fluid to appear at the puncture site. This finding is expected and typically resolves on its own. It does not indicate a complication such as infection or significant bleeding, as long as the drainage remains minimal and there are no other abnormal signs like redness, swelling, or purulent discharge. Therefore, it is not an immediate concern.

B. These vital signs indicate hypotension and compensatory tachycardia, which are concerning for post-paracentesis circulatory compromise. Large-volume paracentesis, such as removing 2,000 mL of ascitic fluid, can lead to rapid shifts in intravascular fluid volume, resulting in decreased circulating blood volume, hypotension, and potential hypovolemic shock. These signs are life-threatening and require immediate action, including close monitoring, intravenous fluid replacement, and notification of the healthcare provider. This is the priority over other findings because hemodynamic instability poses the most immediate risk to the client’s survival.

C. Emotional distress is important and requires supportive care, but it does not constitute an immediate physiological threat. While addressing the client’s anxiety and providing psychological support is essential, it is secondary to stabilizing vital signs and ensuring circulatory adequacy.

D. Weight loss after paracentesis is an expected outcome because the fluid removed contributes to body weight. This finding reflects the therapeutic effect of the procedure and is not a sign of complication.

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After undergoing a liver biopsy, which post-procedure assessment is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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