Examkin

Question

Difficulty: HardReduction of Risk Potential

Two hours following a percutaneous liver biopsy, a client calls the nursing station to report sudden, sharp pain in the right shoulder. Current vital signs reveal a heart rate of 106 beats/minute and a blood pressure of 102/62 mm Hg, compared to a pre-procedure baseline of 78 beats/minute and 126/74 mm Hg. Which action should the practical nurse take first?

  1. A
    Record the assessment findings and plan to recheck the client in 30 minutes
  2. B
    Reposition the client onto the left lateral side to relieve pressure on the biopsy site
  3. Alert the registered nurse about the new symptom and vital sign changesAnswer
  4. D
    Provide the requested oral analgesic to manage the procedural discomfort

Answer

The practical nurse should prioritize reporting these findings to the registered nurse, as they strongly suggest an internal hemorrhage.
Following a liver biopsy, the development of right shoulder pain can indicate diaphragmatic irritation from an internal hemorrhage (subcapsular hematoma). When this symptom is combined with an increased heart rate and decreased blood pressure, it strongly suggests early hypovolemic shock. The practical nurse must immediately alert the registered nurse so that rapid assessment and medical interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends.
The client has developed right shoulder pain, tachycardia, and a dropping blood pressure compared to baseline.
To recognize early signs of a severe post-procedural complication, specifically subcapsular bleeding causing diaphragmatic irritation (referred pain).
2
Determine the appropriate scope of practice for the practical nurse.
The findings represent an acute, unstable change in the client's condition.
Unstable clients or those experiencing acute complications require rapid assessment and intervention beyond the practical nursing scope.
3
Select the priority nursing action.
Alerting the registered nurse is the immediate priority.
To ensure rapid medical escalation and intervention for potential hypovolemic shock.

Key Concept

Identifying early signs of internal bleeding post-liver biopsy (referred shoulder pain, tachycardia, hypotension) and escalating care appropriately.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic