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 A

Explanation

Choice A reason: Blood clots form more easily in mechanical replacement valves due to the artificial surface of the valve, which can cause the blood to clot more readily. This increases the risk of thromboembolic events, such as stroke or valve obstruction. Therefore, patients with mechanical valves need to take anticoagulants for life to prevent clot formation and ensure the valve functions effectively.

Choice B reason: The statement that the vein taken from the leg reduces circulation in the leg is incorrect in this context. Vein grafts from the leg are typically used in coronary artery bypass grafting (CABG) surgery, not in valve replacement surgery. Therefore, this explanation does not apply to the patient's situation of needing anticoagulants after valve replacement surgery.

Choice C reason: The idea that the valve replacement surgery left a lot of small clots in the heart and lungs is not accurate. The surgery itself does not leave clots; rather, the ongoing risk of clot formation is due to the presence of the mechanical valve. This risk necessitates lifelong anticoagulation.

Choice D reason: The mechanical valve does not place the patient at a greater risk for a heart attack specifically. The concern with mechanical valves is the increased risk of blood clot formation, which is why anticoagulants are prescribed. Heart attacks are typically caused by blockages in the coronary arteries, which is a different issue.

A. Decerebrate posturing. B. Flexion withdrawal. C. Decorticate posturing. D. Localization of pain.

Correct Answer is A

Explanation

Choice A reason: Decerebrate posturing is characterized by the extension of the arms and legs, pronation of the arms, and plantar flexion. This type of posturing indicates severe brain damage, typically involving the brainstem. It is a sign of a more serious injury than decorticate posturing and suggests that the damage has progressed to affect the brainstem.

Choice B reason: Flexion withdrawal is a response to a painful stimulus where the patient pulls away from the pain. It is a reflex that indicates some level of preserved spinal cord or brainstem function. However, it does not involve the specific pattern of extension and pronation seen in decerebrate posturing.

Choice C reason: Decorticate posturing involves flexion of the arms, clenched fists, and extension of the legs. The arms are bent inward toward the body with the wrists and fingers flexed on the chest. This posturing indicates damage to the brain's cortical areas or the corticospinal tract. It is less severe than decerebrate posturing.

Choice D reason: Localization of pain is a response where the patient moves a hand towards the site of the painful stimulus, indicating a higher level of brain function. This response suggests that the brain can still process and respond to the location of the pain, which is not consistent with the described posturing.

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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 nurse cares for a patient recovering from mechanical valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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