Question

A client with hepatitis \(\mathrm{C}\) returned from a liver biopsy with complaints of shortness of breath. Which assessment should the nurse make first? A. Auscultation of breath sounds B. Liver biopsy site assessment C. Mental status D. Motor strength and movement of extremities

Short answer

Answer: A. Auscultation of breath sounds.

Step-by-step solution

Analyze option A (Auscultation of breath sounds)

Assessing the patient's breath sounds through auscultation can provide vital information about the client's respiratory status, which may be compromised due to shortness of breath. Auscultation of breath sounds can reveal abnormalities such as wheezing, crackles, or decreased breath sounds, which may indicate respiratory distress.

Analyze option B (Liver biopsy site assessment)

Assessing the liver biopsy site is essential to check for complications like bleeding or infection. While it is necessary to assess the site, the client's primary complaint is shortness of breath, which is not directly related to the biopsy site.

Analyze option C (Mental status)

Mental status assessment may provide information about the patient's level of consciousness, orientation, and cognitive functioning. However, it may not provide immediate information about the cause of the shortness of breath experienced by the client.

Analyze option D (Motor strength and movement of extremities)

Assessing motor strength and movement of extremities can give information about the client's neurological and musculoskeletal status. However, it is not directly related to the client's main complaint of shortness of breath.

Evaluate and select the priority assessment

Out of the four options, auscultation of breath sounds (option A) is the most relevant and urgent assessment for a client complaining of shortness of breath. It provides direct information about the patient's respiratory status, which is crucial in determining the cause of their shortness of breath and guiding further interventions. So, the most appropriate first assessment for the nurse is: A. Auscultation of breath sounds.