A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago.

The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute.

Which intervention is most important for the nurse to implement?

Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.

Choice A rationale
Heberden’s nodes are bony swellings that develop at the end joints (distal interphalangeal joints) of fingers, particularly the fingers closest to the nails. They are a characteristic feature of osteoarthritis, a degenerative joint disease. Osteoarthritis causes the protective cartilage in the joints to wear down over time, leading to the development of these bony growths, which can be painful and limit joint movement. Therefore, discussing strategies for managing chronic pain with the patient is the most appropriate action for the nurse to take.
Choice B rationale
While checking the patient’s radial pulses and capillary refill time is a part of a comprehensive physical assessment, it is not directly related to the management of Heberden’s nodes or osteoarthritis.
Choice C rationale
Although Heberden’s nodes are a sign of osteoarthritis, they are not typically an emergency that requires immediate notification of the healthcare provider. They are a common finding in individuals with osteoarthritis and are usually managed with conservative measures such as pain management and physical therapy.
Choice D rationale
Reviewing the patient’s dietary intake of high-protein foods is not directly related to the management of Heberden’s nodes or osteoarthritis. While a balanced diet is important for overall health, it does not specifically address the pain and limited joint movement associated with Heberden’s nodes.