Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is admitting a client who has just returned to the unit following a percutaneous liver biopsy. The client is currently alert and oriented, with stable vital signs. To reduce the risk of post-procedure complications, which of the following actions should the nurse prioritize?

  1. Position the client in a right lateral decubitus position with a small folded towel under the puncture site.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to optimize diaphragmatic excursion and respiratory effort.
  3. C
    Delegate the continuous monitoring of the abdominal dressing for signs of bleeding to the unlicensed assistive personnel (UAP).
  4. D
    Palpate the client's abdomen to assess for firmness or distention before auscultating for bowel sounds.

Cevap

The nurse should position the client in a right lateral decubitus position with a small folded towel under the puncture site.
The liver is a highly vascular organ located in the right upper quadrant of the abdomen. Following a percutaneous liver biopsy, the most significant and immediate risk is hemorrhage. By placing the client in a right lateral decubitus position (on their right side) and inserting a small towel under the puncture site, the client's own body weight applies direct, sustained pressure to the liver capsule against the chest wall. This mechanical compression promotes hemostasis and effectively reduces the risk of internal bleeding.

Adım Adım Çözüm

1
Analyze the client's clinical situation.
The client has just undergone a percutaneous liver biopsy, an invasive procedure involving a highly vascular organ.
Understanding the nature of the procedure identifies the potential physiological risks.
2
Identify the primary risk associated with the procedure.
The greatest immediate post-procedure risk is internal hemorrhage due to the liver's rich blood supply.
Anticipating complications is fundamental to the reduction of risk potential.
3
Determine the priority intervention to mitigate this specific risk.
Applying direct, continuous pressure to the biopsy site on the right side of the body promotes hemostasis.
Mechanical compression prevents active bleeding from the puncture tract.
4
Select the corresponding appropriate nursing action.
Positioning the client on their right side (right lateral decubitus) utilizes their own body weight to maintain pressure on the liver capsule.
This positioning is the standard of care to safely minimize post-biopsy bleeding.

Anahtar Kavram

Post-Procedure Risk Mitigation: Liver Biopsy Positioning
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru