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Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is caring for a client who has just returned to the medical-surgical unit following a percutaneous liver biopsy. Which of the following nursing actions should the nurse implement to reduce the risk of post-procedure complications? (Select all that apply.)

  1. Position the client on the right side with a rolled towel placed directly under the puncture site.Cevap
  2. Maintain the client on strict bed rest for 2 to 4 hours following the procedure.Cevap
  3. C
    Perform abdominal assessment by deeply palpating the right upper quadrant before auscultating for bowel sounds.
  4. D
    Place the client in a left lateral decubitus position to relieve pressure on the hepatic capsule.
  5. Assess vital signs frequently and monitor for sudden abdominal pain radiating to the right shoulder.Cevap

Cevap

The appropriate actions are positioning the client on the right side with a towel under the site, maintaining strict bed rest for 2 to 4 hours, and monitoring vital signs along with assessing for right shoulder pain.
Following a liver biopsy, the primary risk is hemorrhage due to the liver's high vascularity. Interventions must focus on promoting hemostasis and early detection of bleeding. Placing the client on their right side with a towel under the ribs applies direct mechanical pressure to the liver capsule. Strict bed rest minimizes intra-abdominal pressure changes that could dislodge a clot. Frequent vital sign checks identify early shock, while right shoulder pain is a critical sign of blood irritating the diaphragm via the phrenic nerve.

Adım Adım Çözüm

1
Analyze the procedure and its primary associated risks.
A percutaneous liver biopsy involves inserting a needle into the highly vascular liver, making internal hemorrhage the most significant and immediate life-threatening complication.
Identifying the primary risk dictates which nursing interventions must be prioritized for complication prevention.
2
Evaluate each positioning and activity option against the risk of hemorrhage.
Positioning on the right side with a towel applies necessary pressure to stop bleeding. Bed rest prevents clot disruption. Left lateral positioning is incorrect as it removes necessary pressure.
Correct positioning and activity restriction are the primary physical methods to achieve hemostasis post-biopsy.
3
Evaluate assessment techniques and monitoring strategies.
Frequent vital signs and watching for referred right shoulder pain are essential to detect internal bleeding. Palpating the abdomen before auscultating is the wrong sequence and dangerous post-biopsy.
Standardized assessment sequences must be maintained, and signs of insidious complications (like referred pain from phrenic nerve irritation) must be recognized early.

Anahtar Kavram

Post-procedure risk reduction for highly vascular organ biopsies focuses on mechanical compression (positioning), activity restriction, and early recognition of internal hemorrhage.
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Reduction of Risk Potential

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