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Question

Difficulty: MediumReduction of Risk Potential

The nurse is conducting initial rounds on a medical-surgical unit. Which client positioning observation requires immediate intervention by the nurse to reduce the risk of complications?

  1. A 54-year-old client who had a percutaneous liver biopsy 1 hour ago and is resting in the left lateral position.Answer
  2. B
    A 32-year-old client who had a diagnostic lumbar puncture 2 hours ago and is resting flat in a supine position.
  3. C
    A 68-year-old client who had a right radial artery cardiac catheterization 3 hours ago and is sitting with the head of the bed elevated 45 degrees.
  4. D
    A 71-year-old client who had a total hip arthroplasty via posterior approach 2 days ago and is resting in a supine position with an abduction pillow between the legs.

Answer

The 54-year-old client who had a percutaneous liver biopsy and is resting in the left lateral position requires immediate intervention.
The correct answer identifies that resting on the left side following a liver biopsy is dangerous. The highly vascular nature of the liver places the client at significant risk for hemorrhage. The client must be positioned on the right lateral side, often with a rolled towel under the puncture site, to apply external pressure to the liver capsule and achieve hemostasis. The nurse must intervene immediately to reposition this client.

Step-by-Step Solution

1
Evaluate the post-procedure positioning requirements for the client who had a liver biopsy.
The client should be in the right lateral position.
Direct pressure on the right side is required to compress the liver capsule against the chest wall, preventing hemorrhage.
2
Evaluate the positioning for the lumbar puncture client.
The client is correctly positioned flat in a supine position.
Supine positioning prevents cerebrospinal fluid leakage and decreases the risk of a spinal headache.
3
Evaluate the positioning for the radial artery cardiac catheterization client.
The client is safely positioned with the head of the bed elevated 45 degrees.
Unlike the femoral approach, radial access does not restrict head elevation.
4
Evaluate the positioning for the total hip arthroplasty client.
The client is correctly positioned with an abduction pillow.
Abduction prevents adduction of the hip, which can cause posterior dislocation of the new joint.

Key Concept

Post-procedure Client Positioning for Complication Prevention
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Topics

Reduction of Risk Potential

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