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Zorluk: OrtaReduction of Risk Potential

An ambulatory care nurse is monitoring a 61-year-old client who underwent a percutaneous needle biopsy of the liver one hour ago. The client is currently lying supine with the head of the bed elevated and reports a new onset of dull right shoulder ache. The current heart rate is 112 beats per minute with a blood pressure of 98/62 mm Hg. Pre-procedure baseline vital signs were a heart rate of 78 beats per minute and a blood pressure of 128/76 mm Hg. Which action is the priority for the nurse to take?

  1. Turn the client onto the right side and place a folded towel under the puncture site.Cevap
  2. B
    Administer the prescribed as-needed intravenous analgesic to relieve the shoulder discomfort.
  3. C
    Keep the client in the current position and repeat the vital sign measurements in 15 minutes.
  4. D
    Assist the client into a high-Fowler's position to reduce intra-abdominal pressure.

Cevap

The priority action is to turn the client onto the right side and place a folded towel under the puncture site to apply pressure and stop potential bleeding.
The client is exhibiting early signs of hypovolemic shock (tachycardia, hypotension) and referred right shoulder pain, which suggests internal bleeding irritating the diaphragm. Turning the client onto the right side applies direct pressure to the liver capsule at the puncture site, which is the immediate priority to tamponade the bleeding.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital sign trends.
The client has developed a new right shoulder ache, a heart rate increase from 78 to 112 bpm, and a blood pressure decrease from 128/76 to 98/62 mm Hg.
Identifying deviations from baseline is necessary to detect post-procedure complications early.
2
Correlate the assessment findings with potential complications of a percutaneous liver biopsy.
The liver is a highly vascular organ. Tachycardia, hypotension, and referred right shoulder pain (phrenic nerve irritation from blood) strongly indicate internal hemorrhage.
Recognizing the pathophysiology of referred pain and early hemorrhagic shock guides the choice of intervention.
3
Determine the priority nursing intervention to mitigate the identified risk.
The immediate action is to apply physical pressure to the biopsy site by positioning the client in the right lateral decubitus position.
Direct pressure on the liver capsule tamponades the bleeding, stabilizing the client before notifying the healthcare provider.

Anahtar Kavram

Mitigating hemorrhage risk following a percutaneous liver biopsy
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Konular

Reduction of Risk Potential

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