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Difficulty: MediumReduction of Risk Potential

A 54-year-old client with a history of chronic hepatitis C and cirrhosis has just arrived at the medical-surgical unit following an ultrasound-guided percutaneous liver biopsy. The client is currently drowsy but arousable, with a baseline blood pressure of 118/76 mmHg and a heart rate of 74 bpm. Which of the following nursing actions are appropriate to reduce the risk of potential complications? Select all that apply.

  1. Position the client in a right lateral decubitus position with a rolled towel under the puncture site.Answer
  2. B
    Elevate the head of the bed to a high Fowler's position immediately to promote optimal airway clearance.
  3. Instruct the client to maintain strict bed rest for the duration prescribed by the healthcare provider.Answer
  4. D
    Palpate the right upper quadrant deeply during the initial assessment to establish a baseline for abdominal rigidity.
  5. Evaluate the client for new-onset right shoulder pain to detect potential diaphragmatic irritation from internal bleeding.Answer
  6. F
    Transition to routine vital sign checks every 4 hours, provided the initial post-procedure blood pressure is stable.

Answer

The correct actions are positioning the client in a right lateral decubitus position, instructing them to maintain strict bed rest, and evaluating for new-onset right shoulder pain.
After a percutaneous liver biopsy, the highest risk to the client is hemorrhage because the liver is highly vascular. Proper risk reduction includes positioning the client on the right side to apply direct pressure to the liver capsule, enforcing strict bed rest to prevent clot dislodgement, and actively assessing for referred right shoulder pain, which is an early indicator of internal bleeding and diaphragmatic irritation.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific risks associated with the procedure.
The client is post-percutaneous liver biopsy, a procedure involving a highly vascular organ that carries a significant risk of severe internal hemorrhage.
Identifying the primary physiological risk directs the priority nursing interventions for safety.
2
Evaluate appropriate positioning and activity requirements for risk reduction.
The client must be placed on the right side to compress the liver against the chest wall, and strict bed rest must be enforced.
Direct pressure and limited movement facilitate clot formation and maintain its integrity at the puncture site.
3
Identify safe and effective assessment techniques for early complication detection.
The nurse must monitor for early signs of shock and referred pain to the right shoulder, while strictly avoiding interventions that could provoke bleeding, such as deep abdominal palpation.
Early detection of subtle signs of decompensation prevents life-threatening hemorrhagic shock without causing iatrogenic injury.

Key Concept

Post-Procedure Complication Prevention (Liver Biopsy)
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Topics

Reduction of Risk Potential

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