Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Gastrointestinal

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The client has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy?
  1. Monitor pulse and blood pressure every 30 minutes until stable and then hourly for up to 24 hours.
  2. Ambulate every 4 hours for the first day as long as client can tolerate this.
  3. Measure urine specific gravity every 8 hours for the next 48 hours.
  4. Maintain NPO status for 24 hours post-biopsy.
Explanation
Answer - A - Complications of liver biopsy include hemorrhage or accidental penetration of biliary canaliculi. The nurse should assess for signs of hemorrhage (increased pulse, decreased BP) every 30 minutes for the first few hours and then hourly for 24 hours. The client should be monitored for fever every 4 hours and remain on bed rest for 24 hours.
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