Question

The nurse observes an unlicensed assistive personnel (UAP) provide care for clients. Which observation by the nurse requires an intervention?

A) A small pillow is placed under the thighs of a client diagnosed with shortness of breath, and the head of the bed is elevated 60 degrees.
B) A pillow is placed under the head and neck of a client who is lying on the right side after a liver biopsy.
C) A client diagnosed with hemiplegia lies prone with the lower legs placed on a pillow.
D) A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress.

Answer 1

The nurse must intervene on observation B, where the patient lying on the right side after a liver biopsy is not positioned properly with pressure applied to the site of the biopsy. The client should have a small pillow placed under the puncture site to prevent bleeding.

Step-by-step explanation:

Among the observations made by the nurse regarding the care provided by the unlicensed assistive personnel (UAP), option B would require an intervention. After a liver biopsy, it is critical to position the client in such a way as to prevent bleeding and apply pressure to the biopsy site. A patient should be placed on the right side, with a small pillow under the puncture site to apply pressure and minimize the risk of bleeding, not just under the head and neck. This oversight could lead to post-procedural complications such as hemorrhage, which the nurse must address immediately.

Option A does not require intervention because elevating the head of the bed 60 degrees and placing a small pillow under the thighs can aid breathing in a patient with shortness of breath. Option C is appropriate for a client with hemiplegia as lying prone can promote drainage from the mouth and prevent aspiration. Lastly, option D is a safe positioning for a client with a sacral pressure injury as it relieves pressure on the affected area.