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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client who underwent a percutaneous liver biopsy two hours ago. The client is currently resting in a supine position. The latest vital signs reveal a blood pressure of 102/64 mm Hg, a heart rate of 118 bpm, and a respiratory rate of 20 breaths per minute. The client's baseline heart rate before the procedure was 76 bpm. Which of the following actions should the nurse take first to reduce the risk of a severe complication?

  1. A
    Notify the healthcare provider immediately to report the vital signs and request a blood transfusion.
  2. B
    Elevate the client's lower extremities while maintaining the head of the bed flat to treat hypoperfusion.
  3. Assist the client into a right side-lying position and place a rolled towel under the puncture site.Cevap
  4. D
    Document the vital signs and administer a prescribed analgesic for post-procedural pain.

Cevap

The most appropriate initial action is to assist the client into a right side-lying position and place a rolled towel under the puncture site to apply direct pressure to the liver.
The liver is a highly vascular organ, and hemorrhage is a major life-threatening complication following a percutaneous liver biopsy. The client's new-onset tachycardia (118 bpm) is a classic early physiological indicator of hemorrhagic shock. The immediate, independent nursing priority is to apply direct pressure to the internal bleeding site. Placing the client in a right side-lying position utilizes the body's weight to compress the liver against the chest and abdominal wall, effectively tamponading the bleeding and reducing further physiological risk.

Adım Adım Çözüm

1
Analyze the client's procedural history and current vital signs.
The client had a percutaneous liver biopsy and now exhibits a new onset of tachycardia (heart rate increased from 76 to 118 bpm).
Establishing the baseline and recognizing deviations helps identify early post-procedural complications.
2
Identify the most likely physiological complication associated with these findings.
Because the liver is a highly vascular organ, the sudden tachycardia is a classic early sign of internal bleeding and impending hemorrhagic shock.
Linking the procedure's specific risks to the client's current clinical picture is essential for prioritizing risk reduction.
3
Determine the priority nursing intervention to mitigate this specific risk.
The nurse must immediately apply direct pressure to the internal biopsy site.
Source control of bleeding takes precedence over secondary interventions or provider notification.
4
Select the clinical action that effectively achieves direct internal pressure.
Assisting the client into a right side-lying position with a towel under the puncture site.
This positioning utilizes the client's body weight to compress the liver against the chest wall, effectively tamponading the bleeding.

Anahtar Kavram

Post-procedural hemorrhage mitigation and positioning
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Konular

Reduction of Risk Potential

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