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Zorluk: Çok zorReduction of Risk Potential

An adult client is undergoing post-procedure care on a medical-surgical unit following a percutaneous liver biopsy. The client is currently positioned on the right side with a rolled towel under the puncture site. During the 4-hour post-procedure assessment, the licensed practical nurse notes that the client's heart rate has climbed to 108 beats per minute from a pre-procedure baseline of 76 beats per minute. The blood pressure is currently 104/62 mm Hg, compared to a baseline of 128/74 mm Hg. The client reports new-onset, moderate pain in the right shoulder. Based on these assessment findings, which action must the nurse take to reduce the risk of a severe complication?

  1. Maintain the client in the current position and immediately report the findings to the supervising registered nurse.Cevap
  2. B
    Assist the client into a semi-Fowler's position to alleviate the shoulder discomfort and administer a prescribed analgesic.
  3. C
    Document the referred shoulder pain as an expected procedural outcome and recheck the vital signs in one hour.
  4. D
    Delay further movement, apply supplemental oxygen, and independently initiate a STAT complete blood count draw.

Cevap

The nurse must maintain the client in the right side-lying position to apply continuous pressure to the biopsy site and immediately notify the supervising registered nurse of the findings.
Following a percutaneous liver biopsy, maintaining the client in a right side-lying position is essential to provide direct pressure (tamponade) to the biopsy site, preventing hemorrhage from the highly vascular liver tissue. The client's rising heart rate, dropping blood pressure, and new-onset right shoulder pain (referred pain from diaphragmatic irritation due to internal bleeding) are classic signs of early hypovolemic shock. The priority is to keep the physical pressure on the puncture site and immediately escalate these critical findings to the supervising registered nurse for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's post-operative vital signs.
The heart rate has increased significantly (76 to 108) and blood pressure has decreased (128/74 to 104/62).
These downward trends in blood pressure paired with tachycardia are classic early indicators of hypovolemic shock, likely due to internal hemorrhage.
2
Evaluate the clinical significance of the right shoulder pain.
The pain is recognized as referred pain caused by blood accumulating under the diaphragm and irritating the phrenic nerve.
Combined with the vital sign changes, this confirms a high suspicion of active internal bleeding from the highly vascular liver.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The nurse must keep the client on the right side to maintain pressure on the liver capsule and immediately notify the RN.
Repositioning would remove the tamponade effect, and delaying escalation to draw labs or document would lead to cardiovascular collapse.

Anahtar Kavram

Early Recognition of Post-Procedure Hemorrhage and Appropriate Escalation
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Konular

Reduction of Risk Potential

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