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Question

Difficulty: MediumReduction of Risk Potential

A client with suspected hepatic cirrhosis is transferred to the clinical unit immediately following a percutaneous liver biopsy. Which of the following nursing actions is the priority to reduce the risk of the most significant complication associated with this procedure?

  1. Position the client in a right side-lying position with a folded towel beneath the biopsy site.Answer
  2. B
    Maintain the client in a left lateral decubitus position to promote optimal hepatic blood flow.
  3. C
    Assign the unlicensed assistive personnel to obtain the first set of post-procedure vital signs.
  4. D
    Assess for early indicators of hemorrhagic shock, specifically noting any newly developed bradycardia.

Answer

The priority action is to position the client in a right side-lying position with a folded towel beneath the biopsy site.
The correct answer involves positioning the client on their right side. The liver is a highly vascular organ located in the right upper quadrant of the abdomen. Placing the client in a right side-lying (lateral decubitus) position, often with a small towel or pillow under the puncture site, applies direct external pressure to the liver capsule. This mechanical compression uses the client's body weight to achieve hemostasis and prevent internal hemorrhage, which is the most critical and life-threatening complication following a liver biopsy.

Step-by-Step Solution

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is highly vascular, making internal hemorrhage the most significant and life-threatening post-procedure complication.
Understanding the most critical complication dictates the priority nursing intervention.
2
Determine the appropriate physical intervention to mitigate this risk.
Direct mechanical pressure must be applied to the puncture site to achieve hemostasis.
External compression prevents blood from freely leaking into the peritoneal cavity.
3
Select the correct anatomical positioning to achieve this compression.
Since the liver is located in the right upper quadrant, placing the client in a right lateral position uses the client's own body weight to apply necessary pressure.
Correct positioning is a non-pharmacological, immediate action that significantly reduces the risk of bleeding.

Key Concept

Post-procedure care and positioning to prevent hemorrhage following invasive procedures on highly vascular organs.
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Topics

Reduction of Risk Potential

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