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Difficulty: Very hardReduction of Risk Potential

An older adult client is recovering on the medical-surgical unit 90 minutes after an image-guided percutaneous liver biopsy. The client is currently positioned on the right side with a rolled towel under the lower ribs. During a routine check, the client's blood pressure is 108/68 mm Hg, heart rate is 92 beats/minute, and they report a sudden onset of mild but persistent right shoulder pain. What is the priority action for the practical nurse to take?

  1. Inform the supervising registered nurse immediately about the client's reported symptoms.Answer
  2. B
    Document the shoulder pain as an expected manifestation of prolonged right lateral positioning.
  3. C
    Assist the client into a supine position to alleviate pressure on the right thoracic cage.
  4. D
    Administer the prescribed as-needed oral analgesic and reassess the pain level in 30 minutes.

Answer

Inform the supervising registered nurse immediately about the client's reported symptoms.
Right shoulder pain following a percutaneous liver biopsy is a classic presentation of referred pain caused by diaphragmatic irritation from a subcapsular hematoma or bile leak. Coupled with a heart rate of 92 beats/minute, this indicates a high likelihood of active internal bleeding. The practical nurse must prioritize client safety by immediately escalating these findings to the registered nurse for advanced assessment and rapid intervention.

Step-by-Step Solution

1
Analyze the client's post-procedure requirements.
The client had a highly vascular procedure (liver biopsy) and is at high risk for hemorrhage.
Understanding the specific risks of the procedure establishes the baseline for evaluating new data.
2
Evaluate the clinical data and the client's new symptom.
The client has slight tachycardia (92 bpm) and new right shoulder pain.
Vital signs and pain characteristics must be correlated with potential complications.
3
Correlate the shoulder pain with anatomical pathology.
Right shoulder pain is recognized as referred pain from the phrenic nerve due to blood or bile irritating the diaphragm.
Distinguishing expected discomfort from pathological referred pain is crucial for clinical judgment.
4
Determine the appropriate practical nursing action.
Escalate the finding immediately to the registered nurse.
A potential hemorrhage is unstable and requires comprehensive RN assessment and provider notification, which exceeds independent PN scope.

Key Concept

Recognition of referred pain as a sign of post-procedural internal hemorrhage
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Reduction of Risk Potential

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