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 ["C","D","E","F"]

Explanation

Choice A reason: Increased serum calcium is not typically associated with advanced liver disease. Hypercalcemia (increased serum calcium) may be seen in conditions like hyperparathyroidism, certain cancers, or excessive vitamin D intake, but it is not a common finding in liver disease.

Choice B reason: Decreased serum ammonia is also not associated with advanced liver disease. In fact, patients with liver disease often have increased serum ammonia levels due to the liver's inability to effectively detoxify ammonia into urea. Elevated ammonia can lead to hepatic encephalopathy, a serious complication of liver disease.

Choice C reason: Increased ALT and AST are common laboratory findings in advanced liver disease. These liver enzymes, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), are released into the bloodstream when liver cells are damaged or inflamed. Elevated levels indicate liver injury or dysfunction and are often used to assess the extent of liver disease.

Choice D reason: Decreased albumin is a typical finding in advanced liver disease. Albumin is a protein produced by the liver, and its levels drop when the liver is no longer able to synthesize it effectively. Low albumin levels can lead to edema and ascites due to decreased oncotic pressure in the blood vessels.

Choice E reason: Elevated bilirubin is expected in advanced liver disease. Bilirubin is a byproduct of red blood cell breakdown that is normally processed and excreted by the liver. When liver function is impaired, bilirubin accumulates in the blood, leading to jaundice, characterized by yellowing of the skin and eyes.

Choice F reason: Elevated prothrombin time (PT) is a common finding in advanced liver disease. The liver produces clotting factors necessary for blood coagulation, and when it is damaged, these factors are not produced adequately, leading to prolonged PT. This indicates a higher risk of bleeding and impaired clotting function.

A. The client diagnosed with mitral valve stenosis who has heart palpitations. B. The client diagnosed with arterial occlusive disease who has intermittent claudication. C. The client diagnosed with deep vein thrombosis who has an edematous right calf. D. The client diagnosed with heart failure who has pink frothy sputum.

Correct Answer is D

Explanation

Choice A reason: The client with mitral valve stenosis experiencing heart palpitations is at risk of complications such as atrial fibrillation, which can lead to embolic events. While this is a serious condition that needs attention, it is not as immediately life-threatening as the presence of pink frothy sputum in a heart failure patient.

Choice B reason: The client with arterial occlusive disease and intermittent claudication is experiencing pain due to reduced blood flow to the extremities during activity. Although this condition requires management to prevent worsening ischemia, it is not as critical as the presentation of pink frothy sputum in a heart failure patient.

Choice C reason: The client with deep vein thrombosis (DVT) and an edematous right calf is at risk of developing a pulmonary embolism, which is a serious condition. However, the immediate symptoms do not suggest a current life-threatening emergency compared to the client with heart failure and pink frothy sputum.

Choice D reason: The client with heart failure who has pink frothy sputum must be assessed first. Pink frothy sputum is a sign of pulmonary edema, indicating severe left-sided heart failure. This condition is a medical emergency as it impairs gas exchange and can lead to respiratory failure if not promptly treated. Immediate intervention is necessary to stabilize the client's respiratory and cardiac status.

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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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