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Zorluk: OrtaReduction of Risk Potential

A nurse is caring for a 58-year-old client who returned to the unit two hours ago following a percutaneous liver biopsy. The client reports mild right upper quadrant pain. The current vital signs are: blood pressure 98/60 mm Hg, heart rate 112 beats/min, and respiratory rate 20 breaths/min. Which action should the nurse take immediately to minimize the client's physiological risk?

  1. Place the client in a right side-lying position and notify the healthcare provider of the vital sign trends.Cevap
  2. B
    Reassure the client that mild pain is expected and document the vital signs as a normal response to procedural anxiety.
  3. C
    Elevate the head of the bed to 45 degrees and encourage coughing and deep breathing exercises to prevent atelectasis.
  4. D
    Quickly palpate the client's abdomen for rigidity before auscultating bowel sounds to assess for internal bleeding.

Cevap

Place the client in a right side-lying position and notify the healthcare provider of the vital sign trends.
After a percutaneous liver biopsy, the client is at a high risk for hemorrhage. Positioning the client on the right side applies direct pressure to the liver capsule against the chest wall, promoting hemostasis and reducing the risk of bleeding. Furthermore, the client's tachycardia and borderline low blood pressure are early physiological indicators of hypovolemic shock, meaning the healthcare provider must be notified immediately to initiate further interventions.

Adım Adım Çözüm

1
Analyze the client's vital signs and clinical presentation.
The resting heart rate of 112 beats/min and blood pressure of 98/60 mm Hg are identified as abnormal indicators of possible internal hemorrhage.
Recognizing early signs of hypovolemic shock is critical for post-procedure risk reduction.
2
Determine the appropriate physical positioning for a post-liver biopsy client.
The right side-lying position is required.
Applying direct physical pressure to the biopsy site against the chest wall promotes hemostasis and prevents bleeding.
3
Formulate the immediate nursing intervention.
The nurse must simultaneously correct the client's position for hemostasis and escalate the assessment findings to the provider.
Prompt medical intervention and ongoing monitoring are necessary to manage suspected bleeding.

Anahtar Kavram

Reduction of Risk Potential: Post-Procedure Hemorrhage Mitigation
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Konular

Reduction of Risk Potential

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