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Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. What is the priority nursing action to reduce this client's risk for post-procedure hemorrhage?

  1. A
    Maintain the client in a high-Fowler's position to facilitate maximal lung expansion and prevent atelectasis
  2. Assist the client into a right side-lying position and place a small rolled blanket directly under the puncture siteCevap
  3. C
    Assign the unlicensed assistive personnel (UAP) to monitor and record the client's vital signs every fifteen minutes
  4. D
    Assess the client for a bounding peripheral pulse and a widening pulse pressure as early indicators of internal bleeding

Cevap

The priority action is to assist the client into a right side-lying position and place a small rolled blanket directly under the puncture site.
The liver is a highly vascular organ, making hemorrhage a significant and life-threatening risk following a percutaneous biopsy. Assisting the client into a right side-lying (lateral decubitus) position with a small rolled blanket or towel under the puncture site applies direct physical pressure to the liver capsule against the chest wall. This external pressure promotes hemostasis and is the most critical immediate intervention to reduce the risk of internal bleeding.

Adım Adım Çözüm

1
Identify the primary risk associated with a percutaneous liver biopsy.
The liver is a highly vascular organ, making internal hemorrhage the most critical immediate post-procedure complication.
Understanding the most dangerous potential complication determines the priority nursing intervention for risk reduction.
2
Determine the physical intervention that best mitigates this bleeding risk.
Direct, sustained pressure must be applied to the abdominal puncture site to promote localized hemostasis.
External pressure facilitates clot formation and prevents continued bleeding from the highly vascular liver capsule.
3
Select the client position that achieves this direct pressure.
Placing the client in a right side-lying (lateral decubitus) position utilizes the client's own body weight against the bed to compress the right-sided biopsy site.
This non-pharmacological positioning technique is the standard protocol for hemorrhage risk reduction following this specific procedure.

Anahtar Kavram

Post-procedure hemorrhage prevention
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Konular

Reduction of Risk Potential

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