Question

A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

Answer 1

Correct Answers:

"Lie on your right side."

Rationale :

💠 Lying on the right side places direct pressure over the liver biopsy site, which is essential to reduce the risk of post-procedure bleeding.

💠 The liver is a highly vascular organ, making hemorrhage the most serious complication after a biopsy.

💠 Right-side positioning promotes hemostasis by stabilizing the puncture site and supporting clot formation.

💠 This position also limits movement of the liver, decreasing disruption of the biopsy tract.

💠 Maintaining the right lateral position allows for early detection of bleeding, such as abdominal pain, hypotension, or tachycardia.

“Lie on your left side.”

💠 Left-side positioning does not apply pressure to the liver biopsy site.

💠 Lack of direct pressure increases the risk of internal bleeding after the procedure.

“Increase your fluid intake.”

💠 Fluid intake instructions are not the immediate priority following a liver biopsy.

💠 Positioning and bleeding prevention take precedence over hydration in the immediate post-procedure period.

“Decrease your fluid intake.”

💠 There is no clinical indication to restrict fluids solely due to a liver biopsy.

💠 Fluid restriction does not reduce bleeding risk or improve biopsy site healing.

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Answer 2

Correct Answers:

"Take acetaminophen as prescribed for pain relief after the procedure."

Rationale :

💠 Acetaminophen is recommended for pain control after a bone marrow biopsy because it provides analgesia without increasing bleeding risk.

💠 Bone marrow biopsies can cause localized soreness and discomfort at the iliac crest, which is effectively managed with mild analgesics.

💠 Unlike NSAIDs or aspirin, acetaminophen does not interfere with platelet function, making it safer post-procedure.

💠 Using acetaminophen helps reduce pain while supporting proper clot formation at the biopsy site.

💠 This medication aligns with standard post-biopsy teaching focused on pain management and bleeding prevention.

“Avoid strenuous activities for 1 week following the procedure.”

💠 Activity restriction is usually limited to 24–48 hours, not an entire week.

💠 Prolonged restrictions are unnecessary and not routinely recommended for uncomplicated biopsies.

“You will lie on your back during the procedure.”

💠 A bone marrow biopsy from the iliac crest is typically performed with the client lying prone or on the side, not supine.

💠 Proper positioning is required to expose the posterior iliac crest, the most common site.

“You will receive general anesthesia for the procedure.”

💠 Bone marrow biopsies are usually done under local anesthesia, not general anesthesia.

💠 General anesthesia would increase risk and is not indicated for this minimally invasive procedure.

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Answer 3

Correct Answers:

Diazepam IV

Rationale :

💠 Intravenous diazepam is the first-line emergency medication for stopping ongoing tonic-clonic seizures (status epilepticus).

💠 IV administration allows rapid onset of action, which is critical when seizures persist beyond 5 minutes.

💠 Benzodiazepines like diazepam enhance GABA activity, suppressing excessive neuronal firing in the brain.

💠 Prompt seizure control prevents hypoxia, metabolic acidosis, and neuronal injury associated with prolonged seizures.

💠 Diazepam IV is appropriate after airway protection and positioning, aligning with priority seizure management protocols.

“Diazepam V.”

💠 Vaginal or rectal routes are not first-choice in acute inpatient emergencies when IV access is available.

💠 These routes have slower and less predictable absorption compared to IV administration.

“Lorazepam PO.”

💠 Oral medications cannot be safely administered during active tonic-clonic seizures.

💠 The onset of action is too slow for an acute seizure emergency.

“Clonazepam PO.”

💠 Clonazepam by mouth is used for long-term seizure management, not acute control.

💠 Oral administration is ineffective and unsafe during active seizures.

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Answer 4

Correct Answers:

Provide assistance with ambulation.

Rationale :

💠 The cerebellum controls balance, coordination, and gait, making impaired ambulation a major safety concern for this client.

💠 Clients with cerebellar tumors commonly experience ataxia, unsteady gait, and poor coordination, increasing fall risk.

💠 Assisting with ambulation helps prevent injury and falls, which are the highest immediate threats to client safety.

💠 Ensuring safe mobility supports the priority nursing goal of injury prevention.

💠 Addressing mobility first aligns with physiologic safety needs, which take precedence over communication or environmental comfort.

“Facilitate retention of facts by repeating instructions.”

💠 Memory and cognition are primarily associated with the cerebral cortex, not the cerebellum.

💠 Repetition may be helpful but does not address the immediate safety risk.

“Place the client in a darkened room.”

💠 A darkened environment may be useful for headaches or photophobia, not cerebellar dysfunction.

💠 Reduced lighting can actually increase fall risk in an unsteady client.

“Speak slowly and clearly.”

💠 Speech changes such as dysarthria may occur, but communication is not the priority concern.

💠 This intervention does not directly prevent injury or address impaired coordination.

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Answer 5

Correct Answers:

Hepatitis A vaccine
Hepatitis B vaccine
Pneumococcal vaccine

Rationale :

Hepatitis A vaccine

💠 The hepatitis A vaccine is available for adults to prevent infection caused by the hepatitis A virus.

💠 Hepatitis A is transmitted via the fecal–oral route, commonly through contaminated food or water.

💠 Vaccination is especially recommended for travelers, healthcare workers, and individuals with chronic liver disease.

💠 The vaccine provides active immunity, reducing the risk of acute viral hepatitis.

💠 Immunization helps limit community spread of this highly contagious infection.

Hepatitis B vaccine

💠 The hepatitis B vaccine is routinely available and recommended for adults.

💠 Hepatitis B is transmitted through blood, sexual contact, and perinatal exposure.

💠 Vaccination significantly reduces the risk of chronic hepatitis, cirrhosis, and hepatocellular carcinoma.

💠 It is strongly advised for healthcare workers and high-risk populations.

💠 The vaccine provides long-term protective immunity.

Pneumococcal vaccine

💠 The pneumococcal vaccine is available for adults to protect against Streptococcus pneumoniae.

💠 It prevents serious infections such as pneumonia, meningitis, and bacteremia.

💠 Adults aged 65 years and older and those with chronic conditions are primary candidates.

💠 Vaccination helps reduce morbidity and mortality from invasive pneumococcal disease.

💠 It is a key component of adult preventive health care.

Hepatitis C vaccine

💠 There is no vaccine currently available to prevent hepatitis C infection.

💠 Prevention relies on screening, early detection, and antiviral treatment, not immunization.

Helicobacter pylori vaccine

💠 A commercial vaccine for Helicobacter pylori does not exist at this time.

💠 Management focuses on antibiotic therapy and acid suppression, not vaccination.

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Answer 6

Correct Answers:

Respiratory rate 30/min

Rationale :

💠 An elevated respiratory rate indicates possible neurologic deterioration in a client with traumatic brain injury.

💠 Tachypnea may signal increased intracranial pressure (ICP) or impaired brainstem function affecting respiratory control.

💠 A respiratory rate of 30/min can lead to hypocapnia, causing cerebral vasoconstriction and reduced cerebral perfusion.

💠 Altered breathing patterns are often early warning signs of worsening neurologic status in TBI clients.

💠 Immediate intervention is required to maintain adequate oxygenation and prevent secondary brain injury.

“Axillary temperature 37.2° C (99° F)”

💠 This temperature is within normal limits and does not indicate acute deterioration.

💠 Mild temperature elevation without neurologic change does not require urgent intervention.

“Apical pulse 100/min”

💠 A pulse of 100/min is at the upper limit of normal for adults.

💠 This finding alone does not suggest increased ICP or acute instability.

“Blood pressure 140/84 mm Hg”

💠 This blood pressure reflects mild hypertension, which can occur due to stress or pain.

💠 It does not represent the classic late sign of increased ICP requiring immediate action.

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Answer 7

Correct Answers:

"The tube decreases pressure within the stomach."

Rationale :

💠 An NG tube is used for gastric decompression, which helps remove air and gastric secretions after abdominal surgery.

💠 Decompression prevents abdominal distention, nausea, and vomiting in postoperative clients following a colectomy.

💠 Reducing gastric pressure protects the surgical site and supports proper healing of the bowel.

💠 The NG tube helps restore normal gastrointestinal function by allowing the intestines to rest.

💠 This intervention lowers the risk of aspiration and discomfort, making it a priority postoperative measure.

“Tube drainage should be rust-colored.”

💠 Normal NG drainage is typically green, yellow, or brown, not rust-colored.

💠 Rust-colored drainage may indicate old blood, which is abnormal and should be reported.

“Nutrition will be provided through the tube.”

💠 NG tubes used postoperatively are commonly for decompression, not feeding.

💠 Enteral nutrition is usually delayed until bowel sounds and function return.

“The tube should be irrigated with sterile water.”

💠 NG tubes are not routinely irrigated unless prescribed by the provider.

💠 Unnecessary irrigation can increase risk of complications, including aspiration.

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Answer 8

Correct Answers:

Urine specific gravity 1.02 (1.005 to 1.03)

Rationale :

💠 A urine specific gravity within the normal range indicates improved water balance, showing reduced excess antidiuretic hormone activity.

💠 In SIADH, excessive ADH causes highly concentrated urine due to water retention; normalization suggests the condition is resolving.

💠 A value of 1.02 reflects appropriate renal excretion of water, rather than continued inappropriate reabsorption.

💠 Effective treatment with hypertonic saline helps correct dilutional hyponatremia, allowing urine concentration to normalize.

💠 This finding demonstrates restoration of normal fluid regulation, a key indicator of improvement in SIADH.

“Sodium 119 mEq/L (136–145 mEq/L).”

💠 This value reflects severe hyponatremia, which is a hallmark of unresolved SIADH.

💠 Sodium levels should rise toward normal as SIADH improves.

“BUN 8 mg/dL (10–20 mg/dL).”

💠 A low BUN indicates ongoing fluid overload and dilution, commonly seen in SIADH.

💠 Resolution would be associated with normalization of BUN levels.

“Calcium 8.7 mg/dL (9–10.5 mg/dL).”

💠 Calcium levels are not a primary indicator of SIADH resolution.

💠 Mild hypocalcemia does not directly reflect improvement in ADH-related fluid imbalance.

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Answer 9

Correct Answers:

Respiratory alkalosis

Rationale :

💠 The pH of 7.50 is above the normal range, indicating alkalosis.

💠 The PaCO₂ of 29 mm Hg is abnormally low, which is consistent with hyperventilation and excessive CO₂ loss.

💠 The HCO₃⁻ level is within normal limits, showing that the kidneys have not yet compensated.

💠 Hyperventilation causes increased CO₂ elimination, directly resulting in respiratory alkalosis.

💠 This pattern reflects an acute respiratory condition, not a metabolic disturbance.

“Respiratory acidosis.”

💠 Respiratory acidosis is associated with elevated PaCO₂, not decreased levels.

💠 The pH would be below normal, which is not seen here.

“Metabolic acidosis.”

💠 Metabolic acidosis presents with low pH and decreased HCO₃⁻, which are absent.

💠 PaCO₂ changes would be compensatory, not the primary issue.

“Metabolic alkalosis.”

💠 Metabolic alkalosis is characterized by elevated HCO₃⁻, which is not present.

💠 The primary disturbance here is respiratory, not metabolic.

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Answer 10

Correct Answers:

"Watch for a decreased heart rate while using this medication."

Rationale :

💠 Systemic absorption may lead to bradycardia and hypotension, especially in older adults or clients with cardiac disease.

💠 The nurse should teach the client to monitor heart rate and report symptoms such as dizziness, fatigue, or fainting.

💠 Timolol lowers intraocular pressure by decreasing aqueous humor production, but its beta-blocking effects extend beyond the eye.

💠 Proper teaching also includes punctal occlusion, which helps reduce systemic absorption and adverse effects.

“Notify the provider if you experience a stinging sensation following administration.”

💠 Mild stinging or burning is a common and expected transient effect of ophthalmic drops.

💠 This sensation alone does not indicate an adverse reaction requiring provider notification.

“You can expect to develop a harmless darkening of the iris.”

💠 Iris darkening is associated with prostaglandin analogs, not beta-blockers.

💠 Timolol does not cause permanent pigment changes.

“This medication can cause the lashes of the affected eye to lengthen.”

💠 Eyelash growth occurs with prostaglandin analogs such as latanoprost.

💠 Timolol does not affect eyelash length or thickness.

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QLexNursing

1 :
A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

2 :
A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?

3 :
A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

4 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 :
A nurse is caring for an adult client who asks about immunizations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply.)

6 :
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

7 :
A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?

8 :
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?

9 :
A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO2 29 mm Hg (35 to 45 mm Hg). and HCO, 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

10 :
A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?

QLexNursing

1 : A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

2 : A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?

3 : A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

4 : A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 : A nurse is caring for an adult client who asks about immunizations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply.)

6 : A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

7 : A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?

8 : A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?

9 : A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO2 29 mm Hg (35 to 45 mm Hg). and HCO, 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

10 : A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?

1 :
A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

2 :
A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?

3 :
A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

4 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

5 :
A nurse is caring for an adult client who asks about immunizations against communicable diseases. The nurse should inform the client that which of the following vaccines are available? (Select all that apply.)

6 :
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?

7 :
A nurse is providing instructions to a newly licensed nurse about NG intubation for a client who is postoperative following a colectomy. Which of the following statements should the nurse include?

8 :
A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?

9 :
A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO2 29 mm Hg (35 to 45 mm Hg). and HCO, 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

10 :
A nurse is teaching a client who has glaucoma and is to start taking timolol. Which of the following information should the nurse include?