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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 actions is the priority for the nurse to take to reduce the risk of a post-procedure complication?

  1. Position the client on the right side with a small pillow or rolled towel under the puncture site.Answer
  2. B
    Position the client on the left side with the head of the bed elevated.
  3. C
    Delegate the immediate post-procedure assessment and vital signs to an unlicensed assistive personnel (UAP).
  4. D
    Perform deep palpation of the right upper abdominal quadrant to assess for hematoma formation.

Answer

Position the client on the right side with a small pillow or rolled towel under the puncture site.
Because the liver is a highly vascular organ located in the right upper quadrant, hemorrhage is the most significant risk following a percutaneous liver biopsy. Placing the client on their right side with a small pillow or towel underneath applies direct external pressure to the liver capsule and the puncture site. This mechanical pressure is essential to promote hemostasis and reduce the risk of severe internal bleeding.

Step-by-Step Solution

1
Identify the primary physiological risk associated with a percutaneous liver biopsy.
The primary risk is hemorrhage because the liver is a highly vascular organ and coagulation may be altered.
Recognizing the most life-threatening post-procedure complication dictates the priority nursing intervention.
2
Determine the physical location of the liver and the mechanics of hemostasis.
The liver is located in the right upper quadrant of the abdomen. Applying direct pressure to a bleeding site promotes clot formation.
Understanding anatomy allows the nurse to use positioning as a therapeutic intervention.
3
Select the nursing action that mechanically reduces the risk of bleeding.
Positioning the client on their right side applies the body's own weight to put pressure on the liver capsule.
This is the standard, evidence-based physical intervention to reduce the risk of internal bleeding immediately following the procedure.

Key Concept

Post-Procedure Complication Prevention (Liver Biopsy)
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Topics

Reduction of Risk Potential

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