Which nursing action is most appropriate after a liver biopsy is performed on a patient with cirrhosis?

Choice A rationale
Pursed-lip breathing can help improve oxygenation and reduce shortness of breath in clients with COPD. However, it is not the priority action when a client reports difficulty breathing.
Choice B rationale
Increasing the oxygen flow rate without a physician’s order can lead to oxygen toxicity or suppress the respiratory drive in clients with COPD. Therefore, this is not the priority action.
Choice C rationale
Coughing and expectorating secretions can help clear the airways, but it is not the priority action when a client reports difficulty breathing.

Choice D rationale
Evaluating the client’s respiratory status is the priority action. The nurse should assess the client’s breath sounds, respiratory rate, use of accessory muscles, and oxygen saturation to determine the severity of the client’s difficulty breathing and guide further interventions.

Choice A rationale
Carcinoembryonic Antigen (CEA) is a protein used as a tumor marker, particularly for cancers of the gastrointestinal tract. It is not directly related to volume depletion caused by gastrointestinal illnesses.
Choice B rationale
B12 level is important for nerve function and the formation of red blood cells. It is not directly related to volume depletion caused by gastrointestinal illnesses.
Choice C rationale
Electrolyte imbalance is the correct answer. Gastrointestinal illnesses often cause symptoms such as vomiting and diarrhea, which can lead to significant loss of fluids and electrolytes.
Monitoring electrolyte levels is crucial in these cases to prevent complications related to volume depletion.

Choice D rationale
Hemoglobin level is an indicator of the amount of oxygen-carrying protein in the blood. While it is an important lab value, it is not the most relevant in the context of volume depletion due to gastrointestinal illnesses.