The nurse assists a health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position?

Correct Answer: C

Rationale: Placing the client in a left side-lying position after a liver biopsy helps to promote pressure on the puncture site, which can reduce the risk of bleeding. Placing a small pillow or folded towel under the puncture site provides additional support and helps to maintain pressure on the area. This position also helps prevent the client from putting pressure on the abdomen, which could potentially affect the biopsy site and increase the risk of bleeding or complications. Overall, positioning the client on the left side with support under the puncture site is the most appropriate and safest option after a liver biopsy.

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.

Correct Answer: D

Rationale: The nurse's actions exemplify negligence. Negligence is a failure to provide reasonable care that results in harm to a patient. In this scenario, the nurse failed to unclamp the patient's indwelling urinary catheter as instructed by the healthcare provider. This failure to follow proper procedure led to the patient developing a urinary tract infection, which could have been prevented if the nurse had acted with reasonable care. This action does not meet the criteria for malpractice, assault, or battery as those involve intentional harm or professional misconduct, whereas negligence involves a lack of appropriate care or attention.

Correct Answer: C

Rationale: The patient's presentation of jaundice, ascites, spider angiomas, elevated serum bilirubin levels, prolonged prothrombin time, and hypoalbuminemia are all indicative of cirrhosis. Cirrhosis is a late stage of liver disease characterized by liver scarring and poor liver function. Jaundice, which is the yellowing of the skin and eyes due to elevated bilirubin levels, is a common manifestation of liver dysfunction seen in cirrhosis. Ascites, the accumulation of fluid in the abdomen, is also a common complication of cirrhosis. Spider angiomas, which are small blood vessels near the skin's surface, are a result of altered blood flow in the liver due to cirrhosis. Prolonged prothrombin time and hypoalbuminemia are consequences of reduced liver synthesis function in cirrhosis. Hepatic encephalopathy and hepatorenal syndrome

Correct Answer: B

Rationale: The laboratory test used to monitor the therapeutic effect of warfarin therapy is the International Normalized Ratio (INR). Warfarin is a commonly prescribed anticoagulant medication that works by inhibiting the action of vitamin K-dependent clotting factors. Maintaining the INR within the target range specific to the indication for anticoagulation (e.g., DVT prevention or treatment) is essential to balance the risk of bleeding and clotting.