4. Which nursing actions are appropriate following a liver biopsy? Select all that apply.
. Place client in supine, semi-Fowler's position.
. Immediately assist client to turn on right side.
. Check ammonia level every hour for 4 hours.
. Check vital signs every 10–15 minutes for 1–2 hours.
. Place a pillow under the right costal margin.
. Instruct the client to avoid heavy lifting for 1 week after biopsy.
Test-Taking Tip
With any biopsy, think about preventing bleeding and observing for signs of bleeding.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
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Answer 1 is incorrect because this position will not put pressure on the biopsy site, which is needed to prevent bleeding. Answer 2 is correct because right-side positioning exerts pressure on the liver and reduces the chance for bleeding. Answer 3 is incorrect because the risk following a biopsy is bleeding. Answer 4 is correct because there is a risk of bleeding and a change in vital signs would alert the nurse to bleeding. Answer 5 is correct because the pillow adds direct pressure to the biopsy side and increases comfort. Answer 6 is correct because lifting or straining may lead to bleeding.