A client with ascites is admitted to the hospital. The nurse is assessing the client for potential complications related to fluid retention. Which of the following findings would be most concerning and require immediate intervention?

Choice A reason:

Mild ankle edema is not uncommon in clients with fluid retention, such as ascites. While it requires monitoring, it does not indicate an immediate need for intervention.

Choice B reason:

Moderate abdominal distention is a common finding in clients with ascites and should be monitored, but it does not require immediate intervention.

Choice C reason:

Complaints of thirst and dry mouth may indicate dehydration, which should be addressed, but it does not require immediate intervention as other options.

Choice D reason:

This statement is correct. Respiratory distress and cyanosis are concerning findings in a client with ascites, as they may indicate severe pulmonary edema or other respiratory complications that require immediate intervention and medical attention.

Choice A reason:

Monitoring the client's blood pressure during the procedure is essential, but the nurse should prioritize administering an analgesic before the paracentesis to reduce pain and ensure the client's comfort during the procedure.

Choice B reason:

This statement is correct. Administering an analgesic before the procedure can help reduce pain and discomfort associated with paracentesis.

Choice C reason:

Restricting the client's fluid intake before the procedure is not necessary, as paracentesis is typically performed to remove fluid from the abdominal cavity and provide relief for the client.

Choice D reason:

Maintaining a supine position during the procedure is not required. The nurse should position the client comfortably, which may include elevating the head of the bed or placing the client in a side-lying position to facilitate fluid drainage.

QUESTION