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Question

Difficulty: MediumReduction of Risk Potential

A nurse is evaluating a client who has just returned to the clinical unit following a percutaneous liver biopsy. The client is awake, oriented, and reports mild tenderness at the puncture site on the right side. Vital signs are currently stable. Which of the following nursing actions is the priority to minimize this client's risk for immediate post-procedure complications?

  1. A
    Help the client into a semi-upright seated position to facilitate maximum lung expansion.
  2. B
    Perform deep palpation of the right upper abdominal quadrant to monitor for developing hematomas.
  3. Assist the client into a right lateral decubitus position, placing a small rolled towel beneath the costal margin.Answer
  4. D
    Provide the prescribed intravenous opioid analgesic immediately to ensure the client remains completely still.

Answer

The priority action is to assist the client into a right lateral decubitus position, placing a small rolled towel beneath the costal margin.
Following a percutaneous liver biopsy, the most critical risk is hemorrhage due to the liver's extensive blood supply. Positioning the client on their right side (right lateral decubitus) and placing a rolled towel or sandbag under the costal margin uses the client's body weight to apply direct pressure to the liver against the chest wall. This mechanical compression promotes hemostasis and prevents bleeding.

Step-by-Step Solution

1
Identify the primary physiological risk following a percutaneous liver biopsy.
The most significant immediate risk is internal hemorrhage because the liver is a highly vascular organ.
Recognizing the most lethal potential complication dictates the immediate nursing priority.
2
Determine the physical mechanism needed to mitigate this specific bleeding risk.
Direct mechanical compression must be applied externally to the puncture site.
External pressure promotes hemostasis and clot formation, preventing blood from pooling in the abdominal cavity.
3
Select the nursing intervention that safely achieves this mechanical compression.
Placing the client in a right lateral decubitus (right side-lying) position with a towel or sandbag under the lower rib cage uses the client's own body weight to compress the liver.
This physical positioning directly reduces the risk of hemorrhage, making it the highest priority action upon the client's return.

Key Concept

Post-Procedure Complication Prevention: Liver Biopsy Positioning
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Topics

Reduction of Risk Potential

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