Examkin

Question

Difficulty: HardReduction of Risk Potential

A practical nurse is planning immediate post-procedure care for a client who has just returned to the unit following a percutaneous liver biopsy. Which nursing action correctly mitigates the risk of a severe complication?

  1. Positioning the client on their right side with a rolled towel placed directly under the biopsy site.Answer
  2. B
    Placing the client in a high-Fowler's position to promote optimal lung expansion and oxygenation.
  3. C
    Delaying notification to the registered nurse for a new resting heart rate of 105 beats per minute if the blood pressure is stable.
  4. D
    Assigning the unlicensed assistive personnel to perform the initial baseline evaluation of the puncture dressing.

Answer

Positioning the client in a right lateral decubitus position with a rolled towel under the puncture site to apply direct hemostatic pressure.
The liver is highly vascular, making hemorrhage the most significant risk following a percutaneous liver biopsy. Positioning the client on their right side (right lateral decubitus position) with a rolled towel or small pillow under the puncture site uses the client's own body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression promotes hemostasis and minimizes the risk of internal bleeding.

Step-by-Step Solution

1
Identify the primary complication risk following a percutaneous liver biopsy.
The liver is a highly vascular organ, making severe internal hemorrhage the most critical and immediate post-procedure risk.
Recognizing the specific procedural complication allows the nurse to prioritize targeted preventative interventions.
2
Determine the anatomical location of the liver and the mechanism required to achieve hemostasis.
The liver is located in the right upper quadrant of the abdomen; applying external, mechanical pressure to this area promotes blood clotting at the puncture site.
Direct mechanical pressure compresses the bleeding vessels, significantly reducing the risk of hemorrhage.
3
Select the nursing intervention that effectively applies continuous pressure to the biopsy site.
Positioning the client in a right lateral decubitus (right side-lying) position with a towel or small pillow under the site utilizes the client's own body weight to maintain necessary pressure.
This evidence-based positioning directly mitigates the risk of life-threatening bleeding without requiring constant manual pressure by the nurse.

Key Concept

Post-procedure liver biopsy positioning for hemostasis
Estimated Time:1m 30s
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic