Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

The client's albumin level is increased.

The client's platelet count is normal.

The dressing has a 2-cm area of serous drainage.

The client's heart rate is 122 beats/min.

Answer and Explanation

The Correct Answer is D

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

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Correct Answer is B

Explanation

Choice A reason: Instructing the client to exercise the fingers and wrist is not the immediate priority. While maintaining mobility is important in burn care, the absence of a radial pulse indicates a potential vascular compromise that needs urgent attention.

Choice B reason: Calling the healthcare provider to report the loss of the radial pulse is the correct and immediate action. The absence of a radial pulse suggests that the edema is causing compartment syndrome, which can lead to tissue ischemia and necrosis if not promptly treated. This is a medical emergency requiring immediate intervention, possibly including a fasciotomy to relieve pressure.

Choice C reason: Continuing to assess the arm every hour for additional changes is important, but it is not the immediate priority. The absence of a radial pulse indicates a critical issue that needs immediate reporting and intervention, rather than waiting for further changes.

Choice D reason: Administering morphine IV can help manage the client's pain, which is significant at 8/10. However, it does not address the underlying issue of the absent radial pulse and potential compartment syndrome. Pain management is important but secondary to resolving the vascular compromise.

A. Hepatomegaly. B. Splenomegaly. C. Anuria. D. Ecchymosis.

Correct Answer is D

Explanation

Choice A reason: Hepatomegaly, or enlarged liver, is not a typical finding in DIC. While DIC can affect multiple organs due to widespread microvascular thrombosis and bleeding, hepatomegaly is more commonly associated with other conditions such as liver diseases or congestive heart failure.

Choice B reason: Splenomegaly, or enlarged spleen, is also not a common finding in DIC. Although the spleen can be involved in various hematologic disorders, DIC primarily affects the coagulation and fibrinolytic systems, leading to bleeding and clotting issues rather than spleen enlargement.

Choice C reason: Anuria, or absence of urine production, can occur in severe cases of DIC due to acute kidney injury from microvascular thrombosis or bleeding. However, it is not as common a finding as petechiae, bleeding gums, and ecchymosis. Anuria indicates a critical state requiring immediate intervention but is not the primary expected finding in DIC.

Choice D reason: Ecchymosis, or bruising, is a common finding in DIC. DIC involves widespread activation of the coagulation cascade leading to the consumption of clotting factors and platelets, resulting in bleeding manifestations such as petechiae, bleeding gums, and ecchymosis. These signs indicate the body's inability to form stable clots and the presence of spontaneous bleeding.

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Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

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Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

Correct Answer is B

Explanation

The nurse is caring for a patient in shock with disseminated intravascular coagulation (DIC) and would expect to see the following assessments: petechiae, bleeding gums, and

Correct Answer is D

Explanation

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