Examkin

Soru

Zorluk: OrtaBasic Care and Comfort

A practical nurse is assisting with the admission of a client who has just returned to the nursing unit after a percutaneous liver biopsy. Which of the following positions is most appropriate for the nurse to place the client in to prevent post-procedure complications?

  1. Right side-lying with a rolled towel placed directly under the puncture siteCevap
  2. B
    Left side-lying with the head of the bed elevated 45 degrees
  3. C
    Supine with the knees flexed and arms resting on the abdomen
  4. D
    High Fowler's position with both legs fully extended

Cevap

Right side-lying with a rolled towel placed directly under the puncture site
The correct position is right side-lying with a rolled towel under the puncture site because the liver is located on the right side of the body. Using the client's body weight to press against a towel provides continuous, direct pressure to the biopsy site, which is highly vascular, thereby minimizing the risk of hemorrhage.

Adım Adım Çözüm

1
Identify the procedure performed and the primary associated risk.
The client had a percutaneous liver biopsy, which carries a high risk of internal bleeding due to the liver's high vascularity.
Understanding the procedure's complications is essential for determining the correct preventative nursing intervention.
2
Determine the anatomical location of the liver and the mechanism needed to stop bleeding.
The liver is located on the right side of the abdomen. Applying direct, localized pressure is required to promote hemostasis.
Matching the anatomical site with the physiological need for pressure guides the choice of positioning.
3
Select the client position that best achieves this clinical objective.
Positioning the client on their right side with a towel or pillow under the puncture site uses the client's own body weight to apply pressure.
This specific physical alignment is the standard of care for preventing hemorrhage following a liver biopsy.

Anahtar Kavram

Post-procedure positioning for hemostasis after a liver biopsy
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Konular

Basic Care and Comfort

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