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Difficulty: MediumReduction of Risk Potential

A client returns to the medical-surgical unit following a percutaneous liver biopsy. Which interventions should the practical nurse implement to reduce the risk of post-procedure complications? Select all that apply.

  1. Maintain the client in a right side-lying position.Answer
  2. B
    Assign the unlicensed assistive personnel to evaluate the puncture site for hematoma formation.
  3. C
    Delay reporting a resting heart rate of 112 bpm because the client denies feeling dizzy.
  4. Assess the client's respiratory status and breath sounds bilaterally.Answer
  5. E
    Wait for the provider's daily rounds to report a post-procedure hemoglobin level of 8.2 g/dL.
  6. Instruct the client to avoid forceful coughing or straining.Answer

Answer

The practical nurse should maintain the client in a right side-lying position, assess respiratory status and breath sounds bilaterally, and instruct the client to avoid forceful coughing or straining.
Following a percutaneous liver biopsy, the most significant risks are internal bleeding and accidental puncture of the lung (pneumothorax). The correct interventions actively mitigate these risks: positioning the client on the right side uses the body's weight to apply pressure to the liver capsule; monitoring breath sounds screens for lung injury; and avoiding coughing prevents spikes in intra-abdominal pressure that could disrupt clot formation.

Step-by-Step Solution

1
Identify the primary risks associated with a percutaneous liver biopsy.
The major post-procedure risks are hemorrhage (due to the high vascularity of the liver) and pneumothorax (due to the needle's proximity to the diaphragm).
Understanding the anatomical risks directs the nurse toward the correct preventative and monitoring interventions.
2
Evaluate each action for its effectiveness in preventing or detecting bleeding.
Right side-lying positioning provides hemostasis via compression. Preventing coughing avoids dislodging clots. Tachycardia and low hemoglobin are signs of bleeding that require immediate escalation, not delay.
Prompt recognition and mechanical prevention of bleeding are core responsibilities within the practical nurse scope to reduce risk potential.
3
Evaluate each action for its effectiveness in detecting respiratory compromise.
Auscultating breath sounds bilaterally allows the nurse to detect diminished or absent sounds, which indicate a pneumothorax.
Early detection of airway or breathing complications prevents rapid physiological deterioration.
4
Review the scope of practice regarding delegation.
Delegating the evaluation of a surgical puncture site is inappropriate, as evaluating for a hematoma constitutes an assessment.
Maintaining client safety requires ensuring that tasks are delegated only to appropriately licensed or certified personnel.

Key Concept

Reduction of Risk Potential: Post-Procedural Complications
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Topics

Reduction of Risk Potential

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