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Difficulty: MediumReduction of Risk Potential

A 54-year-old client with a history of chronic hepatitis C has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client's initial vital signs are stable, and they report mild tenderness at the right upper quadrant biopsy site. Which nursing action is the highest priority to reduce the risk of a severe post-procedure complication?

  1. Assist the client into a right lateral position with a small pillow placed under the costal margin.Answer
  2. B
    Elevate the head of the bed to a semi-Fowler's position to facilitate diaphragmatic excursion.
  3. C
    Administer the prescribed intravenous opioid analgesic to manage the reported tenderness.
  4. D
    Assess the client's vital signs and puncture site at four-hour intervals.

Answer

The correct action is to assist the client into a right lateral position with a small pillow placed under the costal margin.
The correct action applies direct pressure to the biopsy site. The liver is a highly vascular organ, making hemorrhage the most significant immediate risk following a percutaneous biopsy. Positioning the client on their right side (right lateral decubitus) with a small pillow or folded towel under the costal margin compresses the liver capsule against the chest wall, promoting hemostasis and effectively reducing the risk of internal bleeding.

Step-by-Step Solution

1
Analyze the client's clinical presentation and the recent procedure.
The client is a 54-year-old who has just undergone a percutaneous liver biopsy and is experiencing expected mild tenderness.
Understanding the specific invasive procedure identifies the primary physiological risks involved.
2
Identify the most significant and immediate risk associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making internal hemorrhage the most severe and immediate procedural complication.
Prioritization requires addressing life-threatening complications before managing expected, mild symptoms.
3
Determine the most effective nursing intervention to mitigate this specific risk.
Positioning the client on their right side with a pillow under the costal margin applies direct pressure to the liver capsule.
Direct physical pressure promotes hemostasis and prevents bleeding from the puncture site.

Key Concept

Post-procedure positioning to prevent hemorrhage following a percutaneous liver biopsy.
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Topics

Reduction of Risk Potential

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