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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contact: Hepatitis C is transmitted primarily through blood, not through direct contact (e.g., touching contaminated surfaces). Contact precautions are not necessary unless there are open wounds or excessive body fluid exposure.
B. Standard: Hepatitis C is a bloodborne virus transmitted through exposure to infected blood (e.g., needlestick injuries, IV drug use). Standard precautions, including hand hygiene, glove use, and proper handling of sharps, are sufficient.
C. Droplet: Hepatitis C is not spread via respiratory droplets (e.g., sneezing, coughing). Droplet precautions are unnecessary.
D. Airborne: Hepatitis C is not transmitted via airborne particles (e.g., tuberculosis, measles). Airborne precautions are unnecessary.
Correct Answer is C
Explanation
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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