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Difficulty: MediumReduction of Risk Potential

A nurse is evaluating a client who is 11 hour post-percutaneous liver biopsy. The nurse is monitoring the client to reduce the risk of potential complications. Which of the following assessment findings or client actions require IMMEDIATE nursing intervention? (Select all that apply.)

  1. The client's heart rate has trended upward from 7676 to 114114 beats per minute over the last 3030 minutes.Answer
  2. The client reports a new onset of sharp pain radiating to the right shoulder.Answer
  3. The client exhibits asymmetrical chest expansion and diminished breath sounds on the right side.Answer
  4. D
    The client is lying firmly on their right side with a small rolled towel under the puncture site.
  5. E
    The client's arterial blood gas results demonstrate a pHpH of 7.427.42, PaCO2PaCO_2 of 40 mm Hg40 \text{ mm Hg}, and HCO3−HCO_3^- of 24 mEq/L24 \text{ mEq/L}.
  6. F
    The client expresses mild, localized soreness directly at the biopsy needle insertion site.

Answer

The findings that require immediate intervention are the upward trend in heart rate, the new sharp pain radiating to the right shoulder, and the asymmetrical chest expansion.
Following a percutaneous liver biopsy, the client is at significant risk for severe complications such as hemorrhage, bile peritonitis, and pneumothorax. An increasing heart rate is a subtle but critical early indicator of hypovolemic shock caused by internal bleeding. New onset of sharp pain radiating to the right shoulder is referred pain that strongly suggests diaphragmatic irritation from accumulating blood or bile. Furthermore, asymmetrical chest expansion with diminished breath sounds on the right side indicates a pneumothorax, which can occur if the pleural cavity was inadvertently punctured during the biopsy. All three of these findings indicate acute physiological decompensation and require immediate life-saving nursing and medical interventions.

Step-by-Step Solution

1
Analyze the clinical scenario and procedure.
The client is 11 hour post-percutaneous liver biopsy, a highly vascular organ located near the pleural cavity.
Identifying the specific procedure helps anticipate the most severe physiological risks, namely hemorrhage, bile leak, and pneumothorax.
2
Evaluate each option for signs of physiological decompensation.
Tachycardia indicates potential shock, right shoulder pain indicates diaphragmatic irritation (bleeding/bile leak), and asymmetrical chest expansion indicates pneumothorax.
Early recognition of shock, peritonitis, or respiratory compromise allows for rapid medical intervention to reduce morbidity.
3
Differentiate between life-threatening abnormalities and expected post-procedure outcomes.
Right-side positioning, normal arterial blood gases, and mild localized soreness are either expected outcomes or therapeutic interventions.
Distinguishing normal from abnormal prevents unnecessary interventions and correctly prioritizes life-saving care.

Key Concept

Post-procedural assessment and complication recognition for percutaneous liver biopsy.
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Topics

Reduction of Risk Potential

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