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Difficulty: MediumReduction of Risk Potential

While performing bedside rounding on a gastroenterology unit, a nurse observes a client who had a percutaneous liver biopsy completed 45 minutes ago. Which finding requires the nurse to take immediate corrective action to prevent physiological decompensation?

  1. The client is lying in a left lateral decubitus position while conversing with a family member.Answer
  2. B
    The client complains of a dull, aching sensation radiating into the right shoulder region.
  3. C
    The unlicensed assistive personnel (UAP) is gathering the client's scheduled vital sign measurements.
  4. D
    The client's most recent vital signs demonstrate a pulse pressure of 42 mm Hg.

Answer

The client lying in a left lateral decubitus position requires immediate corrective action to prevent bleeding.
The liver is a highly vascular organ, and hemorrhage is the most dangerous complication following a percutaneous liver biopsy. To reduce this risk, the client must be positioned on their right side (the operative side) for a minimum of 2 hours post-procedure. This uses the client's own body weight to apply direct, external pressure to the liver capsule and puncture site. Lying on the left side removes this pressure and significantly increases the risk of life-threatening bleeding.

Step-by-Step Solution

1
Analyze the post-procedure risks associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making internal hemorrhage the most significant and immediate life-threatening complication.
Identifying the primary risk determines which nursing interventions are essential for prevention.
2
Evaluate each observation to determine if it increases the risk of hemorrhage or indicates a clinical emergency.
Lying on the left side removes external pressure from the biopsy site, drastically increasing the risk of active bleeding.
Direct mechanical pressure is required to facilitate hemostasis at the hepatic puncture site.
3
Differentiate expected procedural findings and routine care from true clinical complications.
Right shoulder pain is an expected referred pain, a pulse pressure of 42 mm Hg is hemodynamically normal, and UAP delegation for vital signs is standard practice.
Clinical prioritization requires distinguishing between stable, expected assessments and true safety hazards.

Key Concept

Post-procedure care and therapeutic positioning to prevent hemorrhage following a liver biopsy.
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Topics

Reduction of Risk Potential

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