7.Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy? a.Assisting to ambulate for the bathroomb.Keeping the patient on the right side for a minimum of 2 hoursc.Taking vital signs every 4 hoursd.Keeping the patient on the left side for a minimum of 4 hoursANS: B Keep the patient lying on the right side for minimum of 2 hours to splint the puncture site. It compresses the liver capsule against the chest wall to decrease the risk of hemorrhage or bile leak. Vital signs are taken every 15 minutes for 30 minutes, then every 30 minutes for 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1461
OBJ: 2 TOP: Liver biopsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 8.Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect? Pneumothorax is a possible complication of paracentesis. The patient’s head of the bed should be raised slightly, but kept on the right side. Oxygen should be administered and the assessment reported to the charge nurse and documented. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1461 OBJ:1TOP neumothorax KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9.Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography? After the procedure, keep the patient NPO until the gag reflex returns. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1464 OBJ:1TOP iagnostic procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
10.The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for: Vasopressin is a strong vasoconstrictor given to try to stop the hemorrhage of the varices. Unfortunately it also constricts all vessels and may cause cardiac ischemia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1467 OBJ: 3 TOP: Vasopressin KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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