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Difficulty: HardPhysiological Adaptation

A practical nurse is monitoring a client who underwent a percutaneous liver biopsy 3 hours ago. The client's current vital signs are blood pressure 102/64 mm Hg, pulse 98 beats/minute, and respirations 20 breaths/minute. Two hours ago, the blood pressure was 126/78 mm Hg and the pulse was 72 beats/minute. The client now reports a new onset of dull right shoulder pain. Which action should the nurse take first?

  1. A
    Administer the prescribed as-needed oral analgesic for the right shoulder pain.
  2. Report the findings to the supervising registered nurse immediately.Answer
  3. C
    Document the findings and continue to monitor the vital signs in 30 minutes.
  4. D
    Assist the client to turn onto the left side with a pillow for support.

Answer

The correct action is to report the findings to the supervising registered nurse immediately.
The client is exhibiting a classic presentation of internal bleeding following a liver biopsy. The trend of an increasing heart rate and decreasing blood pressure indicates early hypovolemic shock, even if the current numbers do not yet meet the strict criteria for severe hypotension. Additionally, blood pooling under the diaphragm irritates the phrenic nerve, causing referred pain to the right shoulder. Because this represents an acute, life-threatening physiological alteration, the practical nurse's immediate priority is to notify the registered nurse so that rapid medical intervention can be initiated.

Step-by-Step Solution

1
Analyze the vital sign trends.
The blood pressure has dropped significantly (from 126/78 to 102/64 mm Hg) and the heart rate has increased (from 72 to 98 beats/minute) over a short period.
Identifying trends in vital signs helps detect early hemodynamic instability before the client enters uncompensated shock.
2
Evaluate the new onset of right shoulder pain.
The pain is identified as referred pain caused by blood accumulating under the diaphragm, irritating the phrenic nerve.
Understanding complication-specific symptoms is critical for safe post-procedure monitoring.
3
Determine the priority practical nursing intervention.
The findings indicate active internal hemorrhage, which requires immediate escalation to the registered nurse.
Internal bleeding is an emergency that requires interventions beyond the practical nurse's scope of practice, making rapid reporting the highest priority.

Key Concept

Early recognition of internal hemorrhage and hypovolemic shock following invasive procedures
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Topics

Physiological Adaptation

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