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Difficulty: MediumReduction of Risk Potential

A nurse is assuming care for a client who just arrived on the medical-surgical unit following a percutaneous liver biopsy. To mitigate the risk of the most significant post-procedural complication, which specific intervention must the nurse execute?

  1. Position the client in a right lateral decubitus position with a small towel placed beneath the puncture site.Answer
  2. B
    Elevate the head of the bed to a semi-Fowler's position to minimize diaphragmatic irritation and referred shoulder pain.
  3. C
    Perform deep abdominal palpation sequentially across all four quadrants to assess for the early formation of a hematoma.
  4. D
    Obtain a stat arterial blood gas (ABG) sample to establish a baseline for identifying early metabolic acidosis.

Answer

The nurse must position the client in a right lateral decubitus position with a small towel placed beneath the puncture site.
The correct answer emphasizes that the liver is a highly vascular organ, making hemorrhage the most significant immediate risk following a percutaneous biopsy. Positioning the client on their right side (right lateral decubitus) with a towel or small pillow under the costal margin applies direct, continuous pressure to the puncture site. This tamponade effect is a critical, non-pharmacological intervention to promote hemostasis and reduce the risk of severe internal bleeding.

Step-by-Step Solution

1
Identify the specific procedure the client has undergone and its primary physiological risk.
The client had a percutaneous liver biopsy. The liver is highly vascular, making post-procedure hemorrhage the most critical immediate complication.
Understanding the anatomy and the nature of the invasive procedure dictates the immediate post-operative nursing priorities.
2
Determine the physiological mechanism required to prevent this specific complication.
Hemostasis must be achieved at the puncture site through the continuous application of direct pressure (tamponade).
External pressure compresses the liver capsule against the chest wall, facilitating clot formation and preventing continuous bleeding into the peritoneum.
3
Select the nursing intervention that best achieves this physiological requirement.
Placing the client in a right lateral (side-lying) position utilizes the client's own body weight against the bed to apply the necessary direct pressure.
This specific positioning strategy directly addresses and mitigates the highest-priority risk for this procedure.

Key Concept

Post-procedure client positioning to prevent hemorrhage following a liver biopsy.
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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