The nurse is caring for the client following a liver biopsy with the assistance of the student nurse. Which action by the student nurse demonstrates an understanding of the post-procedural care?

Obtains the client's vital signs every hour.

Positions the client onto the right side.

Ambulates the client 1-hour post-procedure.

Encourages the client to cough and deep-breathe hourly.

Answer and Explanation

The Correct Answer is B

Rationale:

A. After a liver biopsy, the risk of complications such as hemorrhage is highest in the first few hours. Therefore, vital signs should be assessed every 15 minutes for the first hour, every 30 minutes for the second hour, and then hourly if stable. Waiting an entire hour between assessments is inadequate and could delay detection of hypotension, tachycardia, or other early signs of internal bleeding.

B. After a liver biopsy, it is standard practice to position the client on their right side with a pillow or small cushion under the puncture site. This applies direct pressure to the liver to help achieve hemostasis, reducing the risk of post-procedural bleeding or hematoma formation. Maintaining this position for at least 2 to 4 hours is recommended. This action reflects a clear understanding of post-procedural care and the priority of protecting the biopsy site.

C. Clients are typically instructed to remain on bed rest for 2 to 6 hours, depending on provider protocol. Early ambulation increases intra-abdominal pressure and raises the risk of bleeding or dislodging the clot at the biopsy site, potentially leading to hemorrhage, hypotension, and pain.

D. While coughing and deep breathing are important for preventing pulmonary complications like atelectasis, they should be avoided immediately after a liver biopsy. Forceful coughing or deep breathing increases intra-abdominal pressure, which can disrupt the liver puncture site, cause bleeding, and lead to pain or hematoma formation.

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Correct Answer is B

Explanation

Rationale:

A. Fever is a common finding in acute pancreatitis and may indicate inflammation or infection. While it is clinically significant and should be monitored, it does not immediately threaten circulation or oxygen delivery. Therefore, it is not the highest priority compared to signs of hemodynamic instability.

B. Hypotension is the highest priority because it indicates potential hypovolemia, third-spacing of fluids, or shock—serious complications of acute pancreatitis. Pancreatitis can cause massive fluid shifts into the retroperitoneal space, leading to decreased circulating blood volume and impaired organ perfusion. According to the ABCs (Airway, Breathing, Circulation) and priority frameworks, compromised circulation and signs of shock require immediate intervention to prevent organ failure and death.

C. Abdominal distention is expected in acute pancreatitis due to inflammation, ileus, and fluid accumulation. Although it requires monitoring and can indicate worsening condition, it is not immediately life-threatening unless accompanied by respiratory compromise or severe hemodynamic instability.

D. Elevated serum lipase levels confirm the diagnosis of pancreatitis and help assess severity, but this is a laboratory finding—not an immediate life-threatening clinical manifestation. Lab abnormalities are important for diagnosis and monitoring but do not take priority over unstable vital signs.

A. Follow the sequence of auscultation, inspection, percussion, and palpation, B. Auscultate the bowel sound first then perform palpation and percussion C. Palpate the most painful area progressing to the least painful parts D. Begin with inspection and end with palpation

Correct Answer is B

Explanation

Rationale:

A. The standard physical assessment sequence is usually inspection, auscultation, percussion, and palpation, not beginning with auscultation before inspection. Following the wrong sequence may lead to inaccurate assessment findings.

B. In clients with cirrhosis and possible abdominal complications (e.g., ascites, tenderness), the abdominal assessment should begin with inspection, followed by auscultation before palpation and percussion. Palpation or percussion before auscultation can stimulate bowel activity and give false bowel sound readings. Since this client is also confused, careful auscultation first ensures accurate assessment while minimizing discomfort or distress.

C. Palpation should begin away from painful areas to avoid causing guarding or spasm that can interfere with assessment. Starting with the most painful areas can increase patient discomfort and make it difficult to accurately assess abdominal findings.

D. While inspection is first, auscultation should be performed before palpation and percussion to obtain accurate bowel sounds. Simply ending with palpation without auscultation first does not follow best-practice assessment protocols.

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The nurse is caring for the client following a liver biopsy with the assistance of the student nurse. Which action by the student nurse demonstrates an understanding of the post-procedural care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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