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Difficulty: MediumBasic Care and Comfort

A nurse is providing care for an older adult client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client reports mild abdominal discomfort. During the initial interaction, the nurse observes that the client has developed sudden, new-onset confusion. Which nursing action is most appropriate?

  1. Position the client on their right side with a small pillow under the costal margin and immediately obtain a full set of vital signs.Answer
  2. B
    Assist the client into a left side-lying position to reduce pressure on the puncture site and relieve the reported discomfort.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to obtain the initial post-procedure vital signs and monitor the client's confusion.
  4. D
    Reassure the client that temporary confusion is a normal, age-related response to the stress of a hospital procedure.

Answer

Position the client on their right side with a small pillow under the costal margin and immediately obtain a full set of vital signs.
Positioning the client on the right side applies direct pressure to the liver capsule, promoting hemostasis and preventing hemorrhage. Additionally, sudden confusion is a potential early indicator of hemorrhagic shock or hypoxia, making immediate vital sign assessment critical.

Step-by-Step Solution

1
Identify the procedure performed and its specific post-procedure positioning requirements.
The client had a percutaneous liver biopsy. The liver is highly vascular and located on the right side.
Direct pressure is required to prevent hemorrhage. The right side-lying (lateral decubitus) position uses the client's body weight to apply this pressure against the liver capsule.
2
Evaluate the clinical significance of the new-onset confusion.
Sudden confusion is an abnormal finding that suggests altered cerebral perfusion.
In the context of a highly vascular procedure, confusion is an early sign of hemorrhagic shock and requires immediate vital sign assessment by the registered nurse.
3
Synthesize the appropriate interventions into a prioritized nursing action.
The nurse must safely position the client to prevent further bleeding while simultaneously assessing physiological stability.
Combining proper positioning with immediate assessment addresses both basic care and acute safety needs.

Key Concept

Post-procedure care and positioning following a liver biopsy, along with the recognition of early signs of hemorrhage.
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Topics

Basic Care and Comfort

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