A client received midazolam 2 mg and morphine sulfate 4 mg for a liver biopsy. After the procedure, the nurse positions the client on the right side and monitors the vital signs. Which is the physiological reason for the nurse's intervention?

Provide pressure over the biopsy site.

Keep the client from aspirating.

Lessen the amount of post procedure pain

Facilitate pulmonary expansion

Answer and Explanation

The Correct Answer is A

A. Provide pressure over the biopsy site:

Positioning the client on the right side after a liver biopsy is aimed at providing pressure over the biopsy site. This pressure helps in promoting hemostasis by compressing the blood vessels at the biopsy site, thus reducing the risk of bleeding or hematoma formation. The liver is located on the right side of the body, so positioning the client on the right side applies pressure directly over the liver, aiding in the prevention of bleeding complications.

B. Keep the client from aspirating:

Positioning the client on the right side after a liver biopsy is not primarily aimed at preventing aspiration. Aspiration precautions are typically implemented during procedures where there is a risk of regurgitation or vomiting, such as during anesthesia induction or recovery, rather than specifically after a liver biopsy.

C. Lessen the amount of post-procedure pain:

While positioning can play a role in managing post-procedure pain, the primary reason for positioning the client on the right side after a liver biopsy is to provide pressure over the biopsy site to promote hemostasis. Pain management strategies such as administering analgesics may be utilized to address any discomfort experienced by the client post-procedure.

D. Facilitate pulmonary expansion:

Positioning the client on the right side after a liver biopsy does not directly facilitate pulmonary expansion. Facilitating pulmonary expansion is typically achieved through interventions such as deep breathing exercises, incentive spirometry, and early ambulation rather than positioning alone.

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Correct Answer is D

Explanation

Hemodialysis is a renal replacement therapy used to remove waste products and excess fluid from the blood when the kidneys are unable to perform this function adequately. The physiological processes involved in hemodialysis include:

A) Solute movement toward a solution with a higher concentration:

While solute movement occurs during hemodialysis, it is typically from a solution with a higher concentration to one with a lower concentration, rather than the opposite. This movement facilitates the removal of waste products and excess solutes from the bloodstream.

B) Water movement toward a solution with a lower solute concentration:

Correct. Osmosis is the movement of water across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration. In hemodialysis, water moves out of the bloodstream, across the semipermeable membrane of the dialyzer, and into the dialysate solution, which has a lower solute concentration. This process helps remove excess fluid from the body.

C) Blood cells and protein movement through the semipermeable membrane:

Blood cells and proteins are too large to pass through the pores of the semipermeable membrane in the dialyzer during hemodialysis. Therefore, the primary exchange occurs between smaller molecules such as urea, creatinine, electrolytes, and water.

D) Osmosis of water movement and diffusion of solute movement:

Correct. Hemodialysis involves both osmosis and diffusion. Osmosis refers to the movement of water across a semipermeable membrane from an area of lower solute concentration to an area of higher solute concentration. Diffusion is the movement of solutes from an area of higher concentration to an area of lower concentration. Together, these processes facilitate the removal of waste products and excess fluid from the bloodstream during hemodialysis.

A. It occurs as a complication of a spinal cord injury. B. Muscle weakness is progressive, degenerative, and fatal. C. Mental status changes occur late in the disease. D. Autonomic nervous system and sensory changes occur.

Correct Answer is B

Explanation

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease, is a progressive neurodegenerative disorder affecting motor neurons in the brain and spinal cord. Understanding the pathophysiological process of ALS is crucial for providing accurate information about the disease prognosis to the client. Here's why option B is the correct choice:

A) It occurs as a complication of a spinal cord injury:

This statement is incorrect. ALS is not a complication of a spinal cord injury. While both conditions involve motor neuron dysfunction, they have different etiologies and pathophysiological processes. ALS is characterized by the degeneration of motor neurons in the brain and spinal cord, leading to muscle weakness and atrophy, whereas spinal cord injury results from trauma to the spinal cord.

B) Muscle weakness is progressive, degenerative, and fatal:

Correct. ALS is characterized by progressive degeneration of motor neurons, leading to muscle weakness, atrophy, and eventual paralysis. The disease is relentless and fatal, typically within 2 to 5 years of diagnosis, although survival can vary widely among individuals. As motor neurons degenerate, voluntary muscle control is lost, eventually affecting the ability to speak, swallow, breathe, and move. Respiratory failure is the most common cause of death in ALS patients.

C) Mental status changes occur late in the disease:

While cognitive and behavioral changes can occur in some individuals with ALS, particularly in the later stages of the disease, they are not universal. ALS primarily affects motor neurons, leading to progressive muscle weakness and paralysis. However, some individuals may experience frontotemporal dementia (FTD), a type of cognitive impairment characterized by changes in behavior, personality, and language.

D) Autonomic nervous system and sensory changes occur:

ALS primarily affects motor neurons rather than sensory neurons or the autonomic nervous system. Sensory symptoms such as numbness, tingling, or loss of sensation are not typical features of ALS. Autonomic dysfunction, including changes in heart rate, blood pressure, or bowel and bladder function, is not a prominent feature of ALS.

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A client received midazolam 2 mg and morphine sulfate 4 mg for a liver biopsy. After the procedure, the nurse positions the client on the right side and monitors the vital signs. Which is the physiological reason for the nurse's intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which physiological process supports the exchange of blood concentrations across a semipermeable membrane in the hemodialysis?

Correct Answer is D

Explanation

A client is diagnosed with amyotrophic lateral sclerosis (ALS). Which pathophysiological process should the nurse use when providing the client with information about this disease prognosis?

Correct Answer is B

Explanation

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