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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.
Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.
Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.
Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.
Correct Answer is A
Explanation
Choice A reason: Maintaining nothing by mouth (NPO) and administering intravenous fluids is the best intervention to reduce discomfort in a patient with acute pancreatitis. NPO status helps to rest the pancreas by preventing the secretion of pancreatic enzymes that can exacerbate inflammation and pain. Intravenous fluids are essential to maintain hydration and electrolyte balance while the patient is not eating or drinking.
Choice B reason: Providing small, frequent feedings with no concentrated sweets is not appropriate for a patient with acute pancreatitis. The priority is to keep the patient NPO to rest the pancreas. Introducing any food can stimulate the pancreas and worsen the condition.
Choice C reason: Administering morphine sulfate intramuscularly every 4 hours as needed can help manage pain, but the preferred route for pain medication in acute pancreatitis is intravenous, as it provides quicker relief and avoids the discomfort of intramuscular injections. Pain management is important, but it should be part of a broader plan that includes NPO status and IV fluids.
Choice D reason: Positioning the patient in a flat, supine position is not recommended for reducing discomfort in acute pancreatitis. Patients often find relief in a semi-Fowler's position (head elevated) or by leaning forward, which can help reduce abdominal pain and pressure on the inflamed pancreas.
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