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Soru

Zorluk: OrtaReduction of Risk Potential

A client with hepatic cirrhosis has just returned to the medical-surgical unit following a percutaneous liver biopsy. The client is awake, alert, and reports mild tenderness at the biopsy site. To reduce the risk of the most significant immediate complication, which action is the priority for the nurse to implement?

  1. Assist the client into a right lateral position with a small rolled towel under the puncture site.Cevap
  2. B
    Place the client in a semi-Fowler's position to facilitate lung expansion and prevent atelectasis.
  3. C
    Palpate the client's abdomen deeply to assess for the early development of a retroperitoneal hematoma.
  4. D
    Delegate the initial and subsequent 15-minute vital sign monitoring to the unlicensed assistive personnel.

Cevap

Assist the client into a right lateral position with a small rolled towel under the puncture site.
The liver is a highly vascular organ, and a percutaneous biopsy carries a significant risk of internal hemorrhage. This risk is amplified in clients with hepatic cirrhosis who frequently suffer from coagulopathies. Assisting the client into a right lateral (side-lying) position with a towel or pillow under the puncture site utilizes the client's own body weight to apply direct, continuous pressure to the liver capsule. This mechanical compression promotes hemostasis, prevents hematoma formation, and reduces the risk of life-threatening bleeding.

Adım Adım Çözüm

1
Identify the procedure performed and its major associated physiological risks.
The client underwent a percutaneous liver biopsy, which carries a severe risk of hemorrhage due to the liver's high vascularity and the client's cirrhosis-induced coagulopathy.
Understanding the most dangerous post-procedure risk determines the immediate nursing priorities.
2
Determine the most effective physical intervention to mitigate the bleeding risk.
Applying direct pressure to the biopsy site encourages hemostasis and prevents blood from leaking into the abdominal cavity.
Mechanical compression is a primary physiological mechanism for arresting bleeding from a puncture wound.
3
Select the specific nursing action that achieves optimal site compression.
Positioning the client on their right side (right lateral decubitus) with a towel underneath uses the client's body weight to press the liver against the chest wall.
This is the evidence-based standard of care for immediate post-liver biopsy risk reduction.

Anahtar Kavram

Post-Procedure Risk Reduction: Liver Biopsy Positioning and Hemostasis
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Konular

Reduction of Risk Potential

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