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Zorluk: OrtaBasic Care and Comfort

A practical nurse receives a hand-off report for a client who returned to the medical-surgical unit one hour ago following a percutaneous liver biopsy. The client is currently stable and reports mild tenderness at the biopsy site. Which positioning strategy is essential for the nurse to maintain during this immediate post-procedure period?

  1. A
    Assisting the client into a high-Fowler's position to encourage deep breathing and lung expansion.
  2. B
    Placing the client in a left lateral position with a pillow situated between the knees for spinal alignment.
  3. Maintaining the client in a right side-lying position with a small rolled blanket under the puncture site.Cevap
  4. D
    Keeping the client in a flat supine position with the lower extremities elevated on pillows.

Cevap

Maintaining the client in a right side-lying position with a small rolled blanket under the puncture site.
Following a percutaneous liver biopsy, the client must be positioned on their right side (the operative side). This position, often supplemented by placing a rolled blanket or towel under the puncture site, utilizes the client's own body weight to apply direct, continuous external pressure to the liver capsule. This pressure is critical to achieve hemostasis and prevent internal hemorrhage from the highly vascular liver tissue.

Adım Adım Çözüm

1
Identify the procedure performed and its anatomical location.
The client had a percutaneous liver biopsy. The liver is a highly vascular organ located on the right side of the abdomen.
Understanding the anatomy and the nature of the procedure is essential for determining post-procedure risks.
2
Determine the primary physiological risk following this specific procedure.
The greatest immediate risk following a liver biopsy is internal hemorrhage due to the liver's extensive blood supply.
Nursing care must prioritize basic comfort and safety interventions that mitigate the most severe risks.
3
Select the nursing intervention that directly addresses the risk of hemorrhage.
Applying external pressure to the puncture site achieves hemostasis.
Direct pressure prevents bleeding from the puncture wound.
4
Identify the correct physical position to achieve this goal.
Placing the client in a right side-lying position with a rolled blanket or towel directly under the costal margin uses the client's own body weight to apply continuous pressure.
This specific basic care measure is the standard protocol for post-liver biopsy positioning.

Anahtar Kavram

Post-procedure therapeutic positioning
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Konular

Basic Care and Comfort

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