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Difficulty: EasyReduction of Risk Potential

A client is admitted to the medical-surgical unit directly after undergoing a percutaneous liver biopsy. Which of the following nursing interventions should be implemented to minimize the risk of post-procedure complications? Select all that apply.

  1. Place the client in a right lateral position with a small towel or pillow under the puncture site.Answer
  2. Instruct the client to maintain strict bed rest for the duration prescribed by the healthcare provider.Answer
  3. Assess vital signs every 15 minutes during the initial post-procedure hour.Answer
  4. D
    Assist the client into a high Fowler's position immediately to promote optimal respiratory function.
  5. E
    Document new-onset mild tachycardia as an expected stress response without further assessment.

Answer

The correct interventions include placing the client in a right lateral position, instructing them to maintain strict bed rest, and assessing vital signs every 15 minutes initially.
The correct interventions for a client following a percutaneous liver biopsy focus heavily on preventing and detecting hemorrhage. Placing the client in a right lateral position applies direct, necessary pressure to the liver capsule at the puncture site. Maintaining strict bed rest minimizes movement that could easily dislodge a fragile clot. Additionally, frequent vital sign monitoring ensures that subtle changes, which could indicate internal bleeding, are detected immediately.

Step-by-Step Solution

1
Identify the primary physiological risks associated with the specific procedure.
A percutaneous liver biopsy involves puncturing a highly vascular organ, making hemorrhage the most significant and immediate complication.
Understanding the most dangerous potential complications directs the focus of the nursing care plan toward risk reduction.
2
Select interventions that mechanically and physically prevent bleeding.
Positioning the client on the right side applies direct pressure, and maintaining bed rest prevents clot disruption.
Direct pressure and immobility are standard, evidence-based measures to achieve hemostasis after a percutaneous puncture of an internal organ.
3
Select interventions that allow for the early detection of complications.
Frequent vital sign monitoring is prioritized to catch subtle physiological changes.
Early indicators of shock, such as mild tachycardia, must be recognized immediately rather than dismissed as benign anxiety.

Key Concept

Post-procedure care for a liver biopsy prioritizes the prevention and early detection of hemorrhage through targeted positioning (right side-lying), immobility, and frequent physiological monitoring.
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Reduction of Risk Potential

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