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 ["A","B","C"]

Explanation

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

A. Administer an antipyretic B. Notify the healthcare provider C. Prepare to administer an enema. D. Continue to monitor the client closely

Correct Answer is B

Explanation

peritonitis are present. Treating the underlying cause (perforation) is more urgent than lowering the fever.

B. Notify the healthcare provider: A hard, rigid abdomen with fever indicates possible perforation and peritonitis, which is a medical emergency. The provider must be notified immediately for urgent intervention.

C. Prepare to administer an enema: Enemas are contraindicated in acute diverticulitis due to the risk of perforation.

D. Continue to monitor the client closely: While continued monitoring is always necessary, immediate action (calling the provider) is critical when signs of peritonitis are present.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care? Select All that Apply

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Explanation

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Correct Answer is B

Explanation

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