Question

The nurse cares for a client 1 hour after a percutaneous liver biopsy. The nurse is MOST concerned if which of the following is observed?

  • (1) The client is lying on the right side with a pillow under the costal margin.
  • (2) The client frequently coughs after deep breathing.
  • (3) The LPN obtains the blood pressure and pulse every 15 minutes.
  • (4) The client reports experiencing mild pain radiating to her right shoulder.

Answer

1. The client is lying on the right side with a pillow under the costal margin.

Incorrect- prevents hemorrhage or escape of bile

2. The client frequently coughs after deep breathing.

CORRECT- avoid coughing or straining to prevent hemorrhage

3. The LPN obtains the blood pressure and pulse every 15 minutes.

Incorrect- vital signs monitored q 10–15 min during first hour and q 30 min for next 1–2 hours; assess for hemorrhage

4. The client reports experiencing mild pain radiating to her right shoulder.

Incorrect- expected; may also have mild local pain

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