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Difficulty: MediumBasic Care and Comfort

A practical nurse is providing care for a client who returned to the nursing unit one hour ago following a percutaneous liver biopsy. Which interventions should the nurse implement to promote comfort and ensure client safety? (Select all that apply)

  1. Position the client on the right side with a small rolled towel beneath the puncture site.Answer
  2. Provide a bedpan for elimination needs to maintain strict bed rest requirements.Answer
  3. Dim the room lights and minimize external noise to facilitate a restful environment.Answer
  4. D
    Encourage the client to sit upright in a chair to promote optimal lung expansion.
  5. E
    Attribute a new onset of mild tachycardia and restlessness solely to procedure-related anxiety.
  6. F
    Prioritize administering a requested back rub over performing the scheduled post-procedure vital sign checks.

Answer

The nurse should position the client on the right side with a towel under the puncture site, provide a bedpan to maintain bed rest, and dim the lights to create a restful environment.
Following a liver biopsy, preventing hemorrhage is the primary physiological goal. Positioning the client on the right side applies direct, continuous pressure to the puncture site. Maintaining strict bed rest with the use of a bedpan ensures physical exertion is minimized, further reducing bleeding risks. Finally, controlling the environment by dimming lights addresses the client's basic comfort needs without compromising safety.

Step-by-Step Solution

1
Analyze the procedure and potential complications.
A percutaneous liver biopsy carries a high risk of internal hemorrhage due to the high vascularity of the liver.
Understanding the primary risk determines the necessary safety interventions.
2
Determine the appropriate postoperative positioning.
The client must be placed on their right side with a pillow or towel under the puncture site.
This specific position applies external physical pressure directly to the liver capsule to aid in hemostasis.
3
Identify the required activity level for the client.
The client must remain on strict bed rest and use a bedpan for elimination.
Physical exertion or ambulation increases abdominal pressure and heart rate, which can dislodge clots and cause bleeding.
4
Select basic comfort measures that do not interfere with safety.
Dimming lights and reducing noise promotes necessary rest.
Environmental control provides comfort while supporting the physiological need for bed rest.

Key Concept

Post-procedure basic care, comfort, and positioning to prevent hemorrhage.
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Topics

Basic Care and Comfort

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