Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A practical nurse is caring for a client who returned to the clinical unit following a percutaneous liver biopsy. Which basic care intervention should the nurse implement to minimize the risk of complications?

  1. A
    Place the client in a left Sims' position to facilitate the continuous drainage of bile
  2. B
    Elevate the head of the bed to a high-Fowler's position to promote maximum lung expansion
  3. Position the client on the right side with a rolled towel under the puncture siteCevap
  4. D
    Assist the client with immediate ambulation in the room to prevent deep vein thrombosis

Cevap

Position the client on the right side with a rolled towel under the puncture site.
Following a liver biopsy, the primary risk is hemorrhage because the liver is a highly vascular organ. Positioning the client on the right side (where the liver is located) and placing a rolled towel directly under the puncture site applies mechanical pressure to the liver capsule. This direct pressure facilitates hemostasis and significantly reduces the risk of internal bleeding.

Adım Adım Çözüm

1
Analyze the post-procedure risks associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making internal hemorrhage the most critical and immediate complication.
Identifying the primary risk dictates the physiological priorities for nursing interventions.
2
Determine the physiological effect of positioning on the biopsy site.
Lying on the right side applies direct pressure to the liver capsule against the chest wall and abdominal structures.
Mechanical compression is required to achieve hemostasis at the vascular puncture site.
3
Select the nursing action that provides the appropriate anatomical compression.
Placing the client on the right side with a rolled towel under the site provides the targeted pressure necessary to prevent bleeding.
This directly addresses the highest-priority safety need (circulation/bleeding prevention) through basic care and positioning.

Anahtar Kavram

Post-Procedure Positioning for Hemorrhage Prevention
Tahmini Süre:1m 0s
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Konular

Basic Care and Comfort

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