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Difficulty: MediumReduction of Risk Potential

Two hours following a percutaneous liver biopsy, a client suddenly becomes restless and anxious. The nurse assesses the client and obtains the following vital signs: blood pressure 104/84104/84 mm Hg, heart rate 118118 beats per minute, and respiratory rate 2222 breaths per minute. The client is currently resting on their right side. What is the priority nursing action to reduce the risk of physiological decompensation?

  1. A
    Administer the prescribed as-needed intravenous opioid analgesic to alleviate the client's restlessness.
  2. B
    Transfer the client to a left lateral decubitus position to prevent skin breakdown.
  3. Activate the rapid response team and prepare to initiate an intravenous fluid bolus.Answer
  4. D
    Record the vital signs in the electronic health record and plan to reassess in one hour.

Answer

Activate the rapid response team and prepare to initiate an intravenous fluid bolus.
The client is exhibiting a narrowing pulse pressure, tachycardia, and restlessness, which are early physiological indicators of hemorrhagic shock—a major risk following a liver biopsy. Activating the rapid response team and preparing for intravenous fluid resuscitation are the absolute priority interventions to stabilize the client's rapidly deteriorating hemodynamic status.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation in the context of the recent invasive procedure.
The client has a narrow pulse pressure (104−84=20104 - 84 = 20 mm Hg), tachycardia (118118 beats per minute), and new-onset restlessness two hours after a highly vascular procedure.
A percutaneous liver biopsy carries a significant risk of internal hemorrhage. Recognizing subtle trends in vital signs is essential for early detection.
2
Synthesize the assessment data to determine the underlying physiological complication.
The combination of restlessness (early cerebral hypoxia), tachycardia (cardiac compensation), and a narrowing pulse pressure indicates the early stages of hypovolemic (hemorrhagic) shock.
As circulating blood volume decreases, the heart rate increases to maintain cardiac output, while systemic vasoconstriction raises the diastolic pressure. This narrows the pulse pressure before a significant drop in systolic blood pressure occurs.
3
Select the priority nursing intervention that directly addresses the life-threatening complication.
The immediate action is to activate emergency protocols and prepare for intravenous fluid resuscitation to restore intravascular volume.
Hemorrhagic shock is a medical emergency. The right lateral position must be maintained for local hemostasis, and immediate volume replacement is necessary to prevent profound organ failure.

Key Concept

Early recognition and management of physiological deterioration and hemorrhagic shock following an invasive procedure.
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Reduction of Risk Potential

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