The nurse is caring for a client who returned from a liver biopsy 30 minutes ago. The client presses the call light and upon arrival in the room the client is pale and complaining of feeling as if they might pass out what of the following is the nurses priority action?

Notify the health care provider

Administer a 1-liter bolus of normal saline

Inspect the biopsy site dressing

Position the client on the right side

Answer and Explanation

The Correct Answer is C

A. Notify the health care provider: While notifying the provider is important, assessing the client comes first to determine if there is active bleeding.

B. Administer a 1-liter bolus of normal saline: Fluid resuscitation is used for shock, but the cause of symptoms must be assessed first.

C. Inspect the biopsy site dressing: The most concerning complication after a liver biopsy is internal bleeding, as the liver is highly vascular. Pallor and near-syncope may indicate hemorrhage. The priority action is to assess the biopsy site for bleeding before taking further action.

D. Position the client on the right side: Clients are typically positioned on the right side after a liver biopsy to apply pressure and reduce bleeding risk, but since the client is already experiencing symptoms of hypovolemia, assessment and intervention for potential hemorrhage take precedence.

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Correct Answer is C

Explanation

A. Metoprolol: Beta-blockers reduce portal hypertension and prevent variceal bleeding.

B. Famotidine: H2 blockers reduce gastric acid and help prevent irritation of varices.

C. Mesalamine: Mesalamine is used for inflammatory bowel disease, not cirrhosis.

D. Balloon tamponade: Balloon tamponade is used in severe variceal bleeding.

A. Ask a peer to validate the results. B. Reassess in hours C. Document the findings D. Neely the healthcare provider.

Correct Answer is C

Explanation

A. Ask a peer to validate the results: While confirming findings with a colleague can sometimes be helpful, it is not necessary in this case. Postoperative ileus is common, and the priority is monitoring and documentation.

B. Reassess in hours: The nurse should reassess bowel sounds periodically, but the specific timeframe should be based on hospital policy and clinical judgment. Bowel sounds may be absent for hours to days postoperatively.

C. Document the findings: Documentation is critical as absent bowel sounds are expected after abdominal surgery. However, it should be accompanied by continued monitoring.

D. Notify the healthcare provider: Absence of bowel sounds immediately post-op is not necessarily an emergency. However, if accompanied by other signs (e.g., distention, vomiting, severe pain), notifying the provider would be warranted.

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The nurse is caring for a client who returned from a liver biopsy 30 minutes ago. The client presses the call light and upon arrival in the room the client is pale and complaining of feeling as if they might pass out what of the following is the nurses priority action?

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Naxlex Comprehensive Predictor Exams

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