Examkin

Question

Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is collecting data on a client who underwent a percutaneous liver biopsy 4 hours ago. The client's baseline vital signs were blood pressure 130/82 mm Hg and heart rate 72 beats/minute. Which current assessment finding presents the highest risk for a severe complication and requires immediate escalation to the registered nurse (RN)?

  1. A gradual increase in heart rate to 108 beats/minute and a blood pressure of 102/66 mm HgAnswer
  2. B
    The client reporting a dull, aching right shoulder pain rated as 4 on a 0 to 10 scale
  3. C
    A post-procedure hemoglobin level of 14.2 g/dL (142 g/L) and a hematocrit of 42% (0.42)
  4. D
    The client asking to review the potential long-term risks of the biopsy procedure

Answer

A gradual increase in heart rate to 108 beats/minute and a blood pressure of 102/66 mm Hg
The liver is highly vascular, placing the client at significant risk for internal hemorrhage following a percutaneous biopsy. A narrowing pulse pressure, a drop in systolic blood pressure, and a compensatory increase in heart rate are classic early signs of hypovolemic shock. This finding requires immediate escalation to the RN for intervention.

Step-by-Step Solution

1
Identify the client's procedure and associated risks.
The client had a percutaneous liver biopsy, which carries a high risk for internal hemorrhage due to the liver's vascularity.
Recognizing high-risk procedures guides targeted post-procedure assessments.
2
Compare current vital signs to the established baseline.
The heart rate increased significantly from 72 to 108 beats/minute, and blood pressure dropped from 130/82 to 102/66 mm Hg.
Trend analysis is crucial for detecting subtle, early signs of physiological decline such as shock.
3
Evaluate the remaining findings for severity.
Right shoulder pain is an expected referred pain (phrenic nerve irritation), the hemoglobin is normal, and asking about risks is a non-emergent teaching need.
Prioritization requires differentiating between expected findings, stable data, and life-threatening crises.
4
Select the finding that indicates a life-threatening complication.
The changes in vital signs indicate early hypovolemic shock from internal bleeding.
Internal hemorrhage is an airway, breathing, or circulation (ABC) priority that requires immediate RN and provider intervention.

Key Concept

Post-procedure hemorrhage recognition
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic