NCLEX-RNReduction of Risk PotentialHard
After a percutaneous liver biopsy, a client is positioned on the right side. Thirty minutes later, the client reports increasing abdominal pain radiating to the right shoulder. Blood pressure has decreased from 122/76 mmHg to 100/60 mmHg, and heart rate has increased from 84/min to 112/min. Which action should the nurse take first?
- AAdminister acetaminophen for the referred shoulder pain
- BReposition the client to the left side for comfort
- CEncourage deep breathing to relieve the shoulder discomfort
- DAssess for signs of intra-abdominal bleeding and notify the health care provider
Show answer & explanationAnswer & explanation
Correct answer: D. Assess for signs of intra-abdominal bleeding and notify the health care provider
Referred right shoulder pain from diaphragmatic irritation, combined with falling blood pressure and rising heart rate after a liver biopsy, indicates possible intra-abdominal hemorrhage, a critical complication requiring immediate assessment and provider notification.
Why the other options are wrong
- A. Treating pain without investigating the cause delays recognition of a life-threatening complication.
- B. Repositioning does not address the underlying suspected hemorrhage and may worsen bleeding at the biopsy site.
- C. Deep breathing does not address the underlying hemorrhage causing the referred pain.
Post-Liver Biopsy Hemorrhage
Bleeding after percutaneous liver biopsy can cause referred right shoulder pain from diaphragmatic irritation along with signs of hypovolemic shock.
- Client positioned on right side post-biopsy to tamponade the puncture site
- Referred right shoulder pain signals diaphragmatic irritation from bleeding
- Falling BP and rising HR indicate hemorrhagic shock requiring urgent notification
Memory trick: Shoulder pain after liver biopsy = blood, not bruise