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Difficulty: MediumBasic Care and Comfort

A nurse is caring for an older adult client who returned to the medical unit one hour ago following a percutaneous liver biopsy. The client reports a strong urge to void and requests assistance to walk to the bathroom. Which nursing intervention is the most appropriate?

  1. Explain the requirement for strict bedrest and provide a fracture pan while keeping the client in a right side-lying position.Answer
  2. B
    Assist the client into a supine position with the knees flexed to facilitate the placement of a standard bedpan.
  3. C
    Assign the unlicensed assistive personnel (UAP) to safely transfer the client to a bedside commode.
  4. D
    Inform the client that sudden urinary urgency is a normal age-related change and offer an absorbent brief.

Answer

Explain the requirement for strict bedrest and provide a fracture pan while keeping the client in a right side-lying position.
Following a percutaneous liver biopsy, clients must remain on strict bedrest in a right side-lying (lateral) position for at least two hours. This position applies direct pressure to the liver capsule at the puncture site, minimizing the risk of hemorrhage. Providing a fracture pan allows the nurse to fulfill the client's basic elimination and comfort needs without compromising this critical therapeutic positioning.

Step-by-Step Solution

1
Identify the client's clinical status and recent procedure.
The client is one hour post-percutaneous liver biopsy.
Understanding the procedure dictates the specific post-operative care and mobility restrictions required.
2
Determine the required positioning for a post-liver biopsy client.
The client must remain on strict bedrest in a right side-lying position.
The right side-lying position applies direct physical pressure against the liver capsule and the puncture site, which is essential to prevent hemorrhage.
3
Evaluate the client's request against the physiological safety requirements.
Walking to the bathroom or using a commode is contraindicated due to strict bedrest and the need for sustained right lateral positioning.
Prioritizing physiological safety (hemorrhage prevention) over the preferred method of elimination is necessary.
4
Select the intervention that addresses the basic care need while maintaining safety.
Using a fracture pan while the client remains on their right side.
A fracture pan can be carefully slipped under the client without requiring them to lift their hips or roll off their right side, safely addressing their comfort and elimination needs.

Key Concept

Post-procedure positioning and basic elimination care
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Topics

Basic Care and Comfort

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