Examkin

Question

Difficulty: EasyReduction of Risk Potential

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following interventions should the nurse include in the client's immediate plan of care to reduce the risk of post-procedure complications? Select all that apply.

  1. Position the client on the right side with a small pillow under the puncture site.Answer
  2. Monitor vital signs every 15 minutes for the first hour.Answer
  3. C
    Delegate the initial assessment of the puncture site to the unlicensed assistive personnel (UAP).
  4. D
    Place the client in a high Fowler's position immediately to promote comfort.
  5. Maintain the client on strict bed rest for the prescribed duration.Answer

Answer

The correct interventions are positioning the client on the right side, monitoring vital signs every 15 minutes for the first hour, and maintaining strict bed rest.
Following a percutaneous liver biopsy, the highest priority is mitigating the risk of hemorrhage because the liver is a highly vascular organ. The correct interventions directly address this risk: placing the client on the right side applies direct, physical pressure to the puncture site to promote hemostasis; taking vital signs every 15 minutes allows the nurse to detect early signs of hypovolemic shock (such as a rising heart rate or dropping blood pressure); and maintaining strict bed rest prevents the disruption of the newly formed clot.

Step-by-Step Solution

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is highly vascular, making hemorrhage the most significant immediate post-procedure complication.
Understanding the most likely complication directs the choice of preventative nursing interventions.
2
Evaluate each intervention for its ability to prevent or detect hemorrhage.
Right side-lying positioning applies pressure to the site; frequent vital signs detect early shock; bed rest prevents clot disruption.
Risk reduction relies on both mechanical prevention (pressure, rest) and early physiological detection (vital signs).
3
Eliminate contraindicated or unsafe interventions.
Delegating initial assessment to a UAP and placing the client in high Fowler's position are incorrect and unsafe actions.
Initial assessments must be performed by the RN, and proper positioning is crucial for physiological homeostasis.

Key Concept

Post-procedure care and risk reduction for a highly vascular organ biopsy.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic