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Zorluk: OrtaBasic Care and Comfort

A nurse receives a client who has just been admitted to the medical-surgical unit following a percutaneous liver biopsy. The client's vital signs are stable. Which of the following positions is the most appropriate for the nurse to assist the client into during the initial post-procedure period?

  1. A
    Semi-Fowler's position with the head of the bed elevated 45 degrees
  2. B
    Left lateral Sims' position with the right leg flexed toward the abdomen
  3. Right side-lying position with a small towel roll placed under the puncture siteCevap
  4. D
    Supine position with the legs elevated on pillows above the level of the heart

Cevap

The right side-lying position with a small towel roll placed under the puncture site
The liver is a highly vascular organ located in the right upper quadrant. After a percutaneous liver biopsy, the primary risk is hemorrhage. Assisting the client into a right side-lying position, especially with a towel or small pillow under the puncture site, uses the client's own body weight to apply direct continuous pressure against the chest wall and liver capsule. This mechanical compression promotes hemostasis and reduces the risk of bleeding.

Adım Adım Çözüm

1
Identify the procedure performed and its primary complication.
The client underwent a percutaneous liver biopsy, which carries a high risk of hemorrhage due to the high vascularity of the liver.
Understanding the procedural risks dictates the appropriate post-operative nursing interventions.
2
Determine the anatomical location of the liver and the puncture site.
The liver is located in the right upper quadrant of the abdomen, and the biopsy is typically performed through the right intercostal space.
Anatomical knowledge is required to apply targeted physical interventions.
3
Select the position that minimizes the risk of the primary complication.
Positioning the client on their right side with a towel roll under the ribs applies direct mechanical pressure to the biopsy site, promoting hemostasis.
Direct pressure is the primary physical mechanism used to stop or prevent bleeding after a percutaneous puncture.

Anahtar Kavram

Post-procedure Positioning for Hemostasis
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Konular

Basic Care and Comfort

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