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After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the
client. Which nursing intervention is most important for the RN to implement?
Position client on left side with pillow placed under the costal margin.
Assist the client with voiding immediately after the procedure.
Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
Ambulate client 3 times in first hour with pillow held at abdomen.
Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
Rationale
Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver,
which is highly vascular. The client should be positioned on the right side with a pillow or sandbag
under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for
several hours to decrease the risk of bleeding from the biopsy site.
,A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing
and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should
the registered nurse (RN) identify in the client's history?
Chronic bronchitis.
Gastroesophageal reflux disease (GERD).
Heart failure (HF).
Chronic pancreatitis.
Heart failure (HF)
Rationale
Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload
associated with heart failure which causes pulmonary edema.
,A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the
registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions
should the RN implement to help the client begin the process of dealing with loss? Select all that apply
Establish trust by creating an safe atmosphere for sharing.
Share personal stories about how other clients dealt with grief.
Help the client identify ways to adapt lifestyle to accommodate loss.
Assure the client that their grief will last a short period of time.
Explore ways to assist the client to make new emotional investments.
Establish trust by creating an safe atmosphere for sharing.
Help the client identify ways to adapt lifestyle to accommodate loss.
Explore ways to assist the client to make new emotional investments.
Rationale
Interventions that could aid the client in maneuvering through the stages of grieving and establishing a
foundation to continue life should include creating a safe atmosphere for sharing, helping the client to
identify ways to adapt to a life style without their spouse and exploring ways to make new emotional
investments.
, A client is newly diagnosed with diverticulosis. The registered nurse (RN)is assessing the client's basic
knowledge about the disease process. Which statement by the client conveys the client's understanding
of the etiology of diverticula?
Over use of laxatives for bowel regularity result in loss of peristaltic tone.
Inflammation of the colon mucosa cause growths that protrude into the colon lumen.
Diverticulosis is the result of high fiber diet and sedentary life style.
Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
Rationale
A client who has chronic constipation often strains to pass constipated stool which increases intestinal
pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which
commonly occur in the sigmoid.
After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the
client. Which nursing intervention is most important for the RN to implement?
Position client on left side with pillow placed under the costal margin.
Assist the client with voiding immediately after the procedure.
Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
Ambulate client 3 times in first hour with pillow held at abdomen.
Evaluate vital signs q10 to 20 minutes for 2 hours after procedure.
Rationale
Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver,
which is highly vascular. The client should be positioned on the right side with a pillow or sandbag
under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for
several hours to decrease the risk of bleeding from the biopsy site.
,A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing
and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should
the registered nurse (RN) identify in the client's history?
Chronic bronchitis.
Gastroesophageal reflux disease (GERD).
Heart failure (HF).
Chronic pancreatitis.
Heart failure (HF)
Rationale
Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload
associated with heart failure which causes pulmonary edema.
,A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the
registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions
should the RN implement to help the client begin the process of dealing with loss? Select all that apply
Establish trust by creating an safe atmosphere for sharing.
Share personal stories about how other clients dealt with grief.
Help the client identify ways to adapt lifestyle to accommodate loss.
Assure the client that their grief will last a short period of time.
Explore ways to assist the client to make new emotional investments.
Establish trust by creating an safe atmosphere for sharing.
Help the client identify ways to adapt lifestyle to accommodate loss.
Explore ways to assist the client to make new emotional investments.
Rationale
Interventions that could aid the client in maneuvering through the stages of grieving and establishing a
foundation to continue life should include creating a safe atmosphere for sharing, helping the client to
identify ways to adapt to a life style without their spouse and exploring ways to make new emotional
investments.
, A client is newly diagnosed with diverticulosis. The registered nurse (RN)is assessing the client's basic
knowledge about the disease process. Which statement by the client conveys the client's understanding
of the etiology of diverticula?
Over use of laxatives for bowel regularity result in loss of peristaltic tone.
Inflammation of the colon mucosa cause growths that protrude into the colon lumen.
Diverticulosis is the result of high fiber diet and sedentary life style.
Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
Chronic constipation causes weakening of colon wall which result in out-pouching sacs.
Rationale
A client who has chronic constipation often strains to pass constipated stool which increases intestinal
pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which
commonly occur in the sigmoid.
