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Difficulty: MediumBasic Care and Comfort

A practical nurse is caring for a client who returned to the medical-surgical unit one hour ago following a percutaneous liver biopsy. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

  1. Maintain the client in a right side-lying position.Answer
  2. Place a small pillow or folded towel under the puncture site.Answer
  3. Offer the client a bedpan or urinal for elimination needs.Answer
  4. D
    Assist the client to sit on the edge of the bed to consume a meal.
  5. E
    Administer an intravenous (IV) push opioid analgesic for reports of pain.
  6. F
    Encourage the client to perform deep coughing exercises every hour.

Answer

The correct interventions are to maintain the client in a right side-lying position, place a small pillow under the puncture site, and offer a bedpan for elimination.
The correct actions involve placing the client in a right side-lying position with a towel or small pillow under the puncture site to apply direct, localized pressure to the highly vascular liver. This physical pressure is critical to prevent hemorrhage. Furthermore, because the client must remain on strict bed rest for several hours to maintain this pressure, the nurse must assist with basic care by providing a bedpan or urinal for urinary elimination.

Step-by-Step Solution

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making post-procedure hemorrhage the most significant complication.
Understanding the primary circulatory risk directs the choice of appropriate basic care and positioning interventions.
2
Determine the correct post-procedure positioning to address the risk.
The client must be placed in a right side-lying position with a pillow or towel under the right costal margin.
This specific positioning utilizes the client's own body weight to apply direct, localized pressure to the liver capsule, preventing bleeding.
3
Evaluate the remaining basic care needs based on activity restrictions.
Because the client is on strict bed rest to avoid dislodging the clot, the nurse must provide a bedpan or urinal for elimination rather than allowing ambulation.
Maintaining strict bed rest minimizes intra-abdominal pressure and protects the fragile clot at the puncture site.

Key Concept

Post-procedure positioning and basic care to prevent hemorrhage following a percutaneous liver biopsy.
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Topics

Basic Care and Comfort

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