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Difficulty: Very hardReduction of Risk Potential

A practical nurse (PN) is caring for a client who had a percutaneous liver biopsy 4 hours ago. The client's baseline vital signs were heart rate 76 beats/minute and blood pressure 134/82 mm Hg. The client now reports a new onset of dull right shoulder pain. Current vital signs are heart rate 112 beats/minute, respirations 22 breaths/minute, and blood pressure 102/68 mm Hg. The puncture site dressing is dry and intact. Which action should the PN take first?

  1. A
    Administer the prescribed as-needed oral analgesic for the reported shoulder pain.
  2. B
    Reposition the client to the left lateral decubitus position to promote comfort.
  3. C
    Remove the pressure dressing to inspect the biopsy site for hematoma formation.
  4. Notify the registered nurse immediately regarding the changes in the client's condition.Answer

Answer

Notify the registered nurse immediately regarding the changes in the client's condition.
Right shoulder pain following a percutaneous liver biopsy is a classic indicator of referred pain caused by blood irritating the diaphragm (Kehr's sign). When this symptom is combined with an increasing heart rate and decreasing blood pressure, it strongly signals early hypovolemic (hemorrhagic) shock due to internal bleeding. Because the bleeding is internal—as indicated by the dry and intact abdominal dressing—the practical nurse must prioritize immediately notifying the registered nurse or healthcare provider to initiate rapid emergency interventions.

Step-by-Step Solution

1
Analyze the client's reported symptom of new right shoulder pain.
Identify this as Kehr's sign, which is referred pain indicating diaphragmatic irritation, a common sign of internal hemorrhage after a liver biopsy.
Recognizing anatomical pain referral patterns is critical for identifying non-visible post-procedural complications.
2
Compare current vital signs to baseline.
Note the heart rate increased from 76 to 112 beats/minute, and blood pressure dropped from 134/82 to 102/68 mm Hg.
Tachycardia and narrowing pulse pressure or mild hypotension are compensatory mechanisms indicating early hypovolemic shock.
3
Determine the appropriate nursing intervention within the PN scope of practice.
Conclude that the client is experiencing a life-threatening internal hemorrhage requiring immediate escalation.
The PN must recognize impending shock and immediately notify the RN to facilitate rapid medical intervention, rather than independently treating symptoms or removing dressings.

Key Concept

Recognition of internal hemorrhage and early shock following an invasive procedure.
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Reduction of Risk Potential

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