Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is establishing a plan of care for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. To minimize the client's risk of severe post-procedure complications, which of the following actions should the nurse include in the plan?

  1. Position the client in a right lateral decubitus position with a small towel roll placed directly under the puncture site.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to promote optimal diaphragmatic excursion and oxygenation.
  3. C
    Delegate the immediate post-procedure vital sign assessments to the unlicensed assistive personnel (UAP).
  4. D
    Rely on a significant drop in systolic blood pressure as the primary early clinical indicator of internal hemorrhage.

Cevap

The nurse should position the client in a right lateral decubitus position with a small towel roll placed directly under the puncture site.
Following a percutaneous liver biopsy, the client is at a high risk for internal hemorrhage because the liver is a highly vascular organ. Placing the client in a right lateral decubitus (side-lying) position with a small towel or pillow directly under the puncture site applies essential mechanical pressure (tamponade) to the liver capsule. This action promotes hemostasis and significantly reduces the risk of life-threatening bleeding.

Adım Adım Çözüm

1
Identify the primary physiological risk associated with the specific procedure.
A percutaneous liver biopsy carries a high risk of internal hemorrhage due to the liver's extensive vascular network.
Understanding the most likely and dangerous complication dictates the priority nursing interventions.
2
Determine the physical mechanism needed to mitigate this risk.
Direct mechanical pressure must be applied to the liver capsule at the puncture site to promote hemostasis (blood clotting).
The liver is located on the right side of the abdomen, so external pressure requires specific patient positioning.
3
Select the nursing action that accurately applies this mechanism while adhering to safe practice standards.
Placing the client on their right side (right lateral decubitus) over a small towel roll achieves the necessary tamponade effect.
This is the established standard of care to reduce bleeding risk immediately following a liver biopsy.

Anahtar Kavram

Post-procedure risk reduction and positioning for liver biopsy
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Konular

Reduction of Risk Potential

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