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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The ABG results indicate respiratory acidosis (pH 7.0, PaCO2 66 mmHg) with compensatory metabolic alkalosis (HCO3- 24 mEq/L). The low PaO2 (60 mmHg) suggests hypoxemia.
pH 7.0: The pH is below the normal range (7.35 to 7.45), indicating acidosis.
PaCO2 66 mmHg: The PaCO2 is elevated above the normal range (35 to 45 mmHg), indicating respiratory acidosis.
HCO3- 24 mEq/L: The bicarbonate level is within the normal range (21 to 28 mEq/L), indicating compensatory metabolic alkalosis.
PaO2 60 mmHg: The PaO2 is decreased below the normal range (80 to 100 mmHg), indicating hypoxemia.
These findings suggest that the client is experiencing respiratory failure, which is characterized by inadequate gas exchange resulting in hypoxemia and hypercapnia. In this case, the massive pulmonary embolus is causing ventilation-perfusion (V/Q) mismatch, leading to impaired gas exchange and respiratory compromise. Tachycardia, hypotension, and audible bilateral pulmonary crackles further support the diagnosis of respiratory failure in the context of a massive pulmonary embolus.
Correct Answer is D
Explanation
Pressure injuries, also known as pressure ulcers or bedsores, result from prolonged pressure on the skin, leading to tissue ischemia and damage. Early recognition of the pathophysiological processes involved in pressure injury development is crucial for prevention and timely intervention. Here's why option D is the correct choice:
A) Epidermal fragility and skin excoriation with serous drainage:
This description more closely aligns with the characteristics of a superficial wound or abrasion rather than the early stages of a pressure injury. In pressure injuries, epidermal breakdown may occur later in the process, after prolonged pressure and tissue ischemia.
B) Hypodermal fluid accumulation and blister formation:
While fluid accumulation and blister formation can occur in some types of wounds, such as friction blisters or burns, they are not typically characteristic of the early stages of pressure injury development. Pressure injuries primarily involve tissue ischemia and damage due to pressure and shear forces.
C) Necrotic tissue, purulent exudate, and eschar formation:
This description is more indicative of advanced or severe pressure injuries rather than the early stages. Necrotic tissue, purulent exudate, and eschar formation typically occur in pressure injuries that have progressed to deeper tissue involvement and infection.
D) Ischemic inflammatory response marked by erythemic skin:
Correct. In the early stages of pressure injury development, the affected area may exhibit signs of tissue ischemia and inflammation, which can manifest as erythema (redness) of the skin. This erythema is a result of the body's inflammatory response to tissue damage caused by pressure and may indicate the need for intervention to relieve pressure and prevent further injury.
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