Examkin

Question

Difficulty: HardReduction of Risk Potential

A nurse is evaluating a client who underwent a percutaneous liver biopsy two hours ago. The client is currently resting on their right side with a rolled towel under the puncture site. Which of the following assessment findings requires the most immediate notification to the healthcare provider to reduce the risk of a severe physiological complication?

  1. Sudden onset of dyspnea, pleuritic chest pain, and absent breath sounds at the right lung base.Answer
  2. B
    An arterial blood gas (ABG) analysis revealing a pH of 7.41, PaCO2 of 40 mmHg, and PaO2 of 88 mmHg on room air.
  3. C
    The client reports dull, aching pain referred to the right shoulder and requests to be repositioned to a supine position.
  4. D
    A blood pressure reading of 124/76 mmHg in a client whose pre-procedure baseline was 132/82 mmHg.

Answer

The assessment finding of sudden onset of dyspnea, pleuritic chest pain, and absent breath sounds at the right lung base.
The correct answer describes the classic presentation of a right-sided pneumothorax (dyspnea, pleuritic pain, absent breath sounds). Because the biopsy needle is inserted through the lower right intercostal spaces to access the liver, there is a risk of accidentally puncturing the diaphragm and pleural space. This represents an acute respiratory emergency requiring immediate provider notification for potential chest tube placement.

Step-by-Step Solution

1
Analyze the specific anatomical risks associated with a percutaneous liver biopsy.
Because the liver is highly vascular and located immediately below the diaphragm on the right side, the primary procedural risks are hemorrhage and accidental puncture of the pleural cavity (pneumothorax).
Understanding the anatomy involved dictates which complications to anticipate during post-procedure monitoring.
2
Evaluate each assessment finding to differentiate between expected post-procedure variations and signs of severe decompensation.
Normal ABGs, minor blood pressure fluctuations, and referred right shoulder pain (due to phrenic nerve irritation) are expected or non-emergent. Sudden respiratory distress with absent breath sounds is highly abnormal.
Risk reduction requires the ability to quickly filter out benign data and isolate pathological cues.
3
Apply the ABC (Airway, Breathing, Circulation) framework to prioritize the abnormal findings.
The symptoms of dyspnea and absent right-sided breath sounds indicate a pneumothorax, representing a critical 'Breathing' emergency that takes precedence over other findings.
Airway and breathing compromise lead to rapid physiological deterioration and death if not immediately addressed.

Key Concept

Post-Procedure Complication Recognition (Liver Biopsy)
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic