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Difficulty: MediumReduction of Risk Potential

An adult client is recovering on the medical-surgical unit two hours after a percutaneous liver biopsy. The nurse observes that over the last hour, the client's heart rate has increased from 76 to 114 bpm, and the blood pressure has shifted from 128/80 mm Hg to 110/88 mm Hg. The client reports feeling "restless" and has mild right upper quadrant discomfort. Which action should the nurse take immediately to minimize the risk of a severe complication?

  1. Assess the abdomen for distention or rigidity and immediately notify the healthcare provider.Answer
  2. B
    Assist the client into a high-Fowler's position to promote optimal diaphragmatic excursion.
  3. C
    Document the vital signs as a manifestation of anxiety and continue routine monitoring.
  4. D
    Auscultate bilateral lung sounds and instruct the client to use an incentive spirometer.

Answer

Assess the abdomen for distention or rigidity and immediately notify the healthcare provider.
The correct answer addresses the highest physiological priority: identifying and managing internal hemorrhage. A narrowing pulse pressure (systolic minus diastolic) combined with tachycardia and restlessness are classic early signs of hypovolemic shock. Because the liver is a highly vascular organ, bleeding is a primary risk after a biopsy. The nurse must assess for abdominal rigidity, which indicates intraperitoneal blood accumulation, and alert the provider immediately to prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the trending vital signs.
The pulse pressure has narrowed significantly (from 48 mm Hg to 22 mm Hg) and the heart rate has increased significantly.
Identifying subtle vital sign trends is crucial for detecting early physiological decompensation.
2
Relate the findings to the specific procedure and client symptoms.
The liver is highly vascular; the vital sign changes combined with restlessness indicate early hemorrhagic shock from internal bleeding.
Linking procedure-specific risks to clinical manifestations guides appropriate nursing interventions.
3
Select the intervention that addresses the highest priority risk.
The nurse must assess for signs of intra-abdominal hemorrhage (rigidity) and escalate the findings to the provider.
Circulatory collapse is an immediate life threat requiring rapid medical management.

Key Concept

Early recognition of hypovolemic shock and internal hemorrhage post-procedure
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Topics

Reduction of Risk Potential

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