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Question

Difficulty: MediumReduction of Risk Potential

Following a percutaneous liver biopsy, a client is resting on the medical-surgical unit. The client's pre-procedure baseline showed a blood pressure of 132/82 mm Hg and a heart rate of 72 beats/minute. During an assessment two hours later, the blood pressure measures 108/66 mm Hg with a heart rate of 98 beats/minute, and the client mentions mild aching on the right side. What is the most appropriate next action for the licensed practical nurse to take?

  1. Promptly communicate the changing hemodynamic parameters to the registered nurse.Answer
  2. B
    Record the measurements in the electronic chart and continue with routine monitoring.
  3. C
    Adjust the intravenous pump to deliver a rapid fluid bolus to stabilize circulation.
  4. D
    Prioritize giving the prescribed oral pain medication to relieve the right-sided aching.

Answer

The correct action is to promptly communicate the changing hemodynamic parameters to the registered nurse to ensure rapid intervention for potential internal bleeding.
The client's shift in vital signs—a decreasing blood pressure and increasing heart rate—are early compensatory signs of hypovolemic shock. Because the liver is a highly vascular organ, a percutaneous biopsy carries a significant risk of internal bleeding. The nurse must recognize these subtle trends as a potential life-threatening complication and immediately alert the registered nurse for further evaluation and intervention.

Step-by-Step Solution

1
Analyze the client's current vital signs by comparing them to the pre-procedure baseline.
The blood pressure dropped from 132/82 to 108/66 mm Hg, and the heart rate increased from 72 to 98 beats/minute.
Comparing current data to baseline is essential for identifying early physiological changes rather than just relying on standard adult normal ranges.
2
Correlate the vital sign trends with the specific procedural risks associated with a liver biopsy.
The trends indicate early compensatory shock, likely from internal bleeding due to the liver's high vascularity.
Understanding procedural risks helps differentiate expected post-procedure findings from dangerous complications.
3
Determine the appropriate nursing action based on the practical nurse scope of practice.
The nurse must escalate the findings immediately to the registered nurse.
Recognizing and reporting subtle signs of clinical deterioration reduces the risk of severe adverse outcomes.

Key Concept

Recognizing Early Signs of Hemorrhage and Hypovolemic Shock
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Topics

Reduction of Risk Potential

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