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Zorluk: OrtaReduction of Risk Potential

A nurse is initiating the post-procedure care plan for a client who returned to the medical-surgical unit following a percutaneous liver biopsy. To actively reduce the client's risk for a life-threatening complication, which intervention should the nurse implement?

  1. Position the client on the right side with a small, rolled towel placed directly under the puncture site.Cevap
  2. B
    Maintain the client in a semi-Fowler's position to promote optimal diaphragmatic excursion.
  3. C
    Perform deep palpation of the right upper abdominal quadrant every 15 minutes to monitor for hematoma formation.
  4. D
    Monitor the client for a bounding radial pulse and a widened pulse pressure as early indicators of internal bleeding.

Cevap

Position the client on the right side with a small, rolled towel placed directly under the puncture site.
Following a percutaneous liver biopsy, the most significant risk to the client is internal hemorrhage due to the extensive vascularity of the liver. Placing the client in a right lateral (side-lying) position, especially with a towel or small pillow under the puncture site, utilizes the client's body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression promotes hemostasis and drastically reduces the risk of bleeding.

Adım Adım Çözüm

1
Identify the primary physiological risk following a percutaneous liver biopsy.
Hemorrhage is the most significant and life-threatening post-procedure complication because the liver is a highly vascular organ.
Recognizing the highest risk dictates the priority preventative nursing action.
2
Evaluate how positioning can mitigate the identified risk of hemorrhage.
The liver is located in the right upper quadrant of the abdomen.
Placing the client in a right lateral position uses gravity and the weight of the client's body to compress the area against the mattress.
3
Select the intervention that best applies direct mechanical pressure.
The right side-lying position with a towel underneath directly compresses the liver capsule.
This mechanical pressure is essential to stop venous or arterial oozing from the needle track and promote clot formation.

Anahtar Kavram

Reduction of Risk Potential: Post-Procedure Hemorrhage Prevention
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Konular

Reduction of Risk Potential

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