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Zorluk: OrtaBasic Care and Comfort

Immediately following a percutaneous liver biopsy, an older adult client is transferred to the medical-surgical unit. The client reports mild discomfort near the insertion site and suddenly exhibits new-onset restlessness. Which intervention is the most appropriate action for the nurse to implement?

  1. Assist the client into a right lateral position and place a folded towel directly under the biopsy site.Cevap
  2. B
    Position the client in a high upright seated posture to maximize chest expansion and relieve agitation.
  3. C
    Direct a patient care technician to conduct the immediate sequence of post-procedure vital sign measurements.
  4. D
    Record the sudden increase in restlessness as a typical age-related cognitive response to an unfamiliar hospital environment.

Cevap

The most appropriate immediate action is to assist the client into a right lateral position and place a folded towel directly under the biopsy site.
Following a percutaneous liver biopsy, the client is at a high risk for hemorrhage due to the extreme vascularity of the liver tissue. Placing the client in a right lateral (side-lying) position with a folded towel or small pillow under the costal margin applies direct, sustained external pressure to the liver capsule. This mechanical compression promotes hemostasis, prevents hematoma formation, and is a critical basic care standard for this specific procedure.

Adım Adım Çözüm

1
Analyze the procedural risks associated with the client's recent treatment.
A percutaneous liver biopsy involves puncturing a highly vascular organ, making internal hemorrhage the most significant immediate complication.
Understanding procedural risks is essential for prioritizing immediate post-operative nursing care.
2
Evaluate the clinical significance of the client's symptoms.
The client is exhibiting sudden new-onset restlessness, which is a classic early sign of decreased oxygenation to the brain, potentially indicating occult bleeding.
Recognizing early signs of shock ensures timely intervention before the client becomes hemodynamically unstable.
3
Select the intervention that directly addresses the primary physiological risk.
Placing the client on their right side with a towel underneath applies mechanical pressure to the biopsy site, effectively reducing the bleeding risk.
Physical positioning is a primary basic care and comfort measure used to prevent post-procedural complications.

Anahtar Kavram

Basic Care and Comfort: Post-Procedure Positioning
Tahmini Süre:1m 15s
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Konular

Basic Care and Comfort

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