The nurse assists a health care provider with a paracentesis that removed 2000 mL of fluid for a client with ascites. Which finding is the greatest concern?

The dressing at the paracentesis site has 1 cm of clear drainage.

The blood pressure is 96/48 mmHg, and the heart rate is 115 beats/min.

The client starts crying and says she can't go on with treatment much longer.

The client weighs less post procedure.

Answer and Explanation

The Correct Answer is B

Rationale:

A. After a paracentesis, it is normal for a small amount of clear serous fluid to appear at the puncture site. This finding is expected and typically resolves on its own. It does not indicate a complication such as infection or significant bleeding, as long as the drainage remains minimal and there are no other abnormal signs like redness, swelling, or purulent discharge. Therefore, it is not an immediate concern.

B. These vital signs indicate hypotension and compensatory tachycardia, which are concerning for post-paracentesis circulatory compromise. Large-volume paracentesis, such as removing 2,000 mL of ascitic fluid, can lead to rapid shifts in intravascular fluid volume, resulting in decreased circulating blood volume, hypotension, and potential hypovolemic shock. These signs are life-threatening and require immediate action, including close monitoring, intravenous fluid replacement, and notification of the healthcare provider. This is the priority over other findings because hemodynamic instability poses the most immediate risk to the client’s survival.

C. Emotional distress is important and requires supportive care, but it does not constitute an immediate physiological threat. While addressing the client’s anxiety and providing psychological support is essential, it is secondary to stabilizing vital signs and ensuring circulatory adequacy.

D. Weight loss after paracentesis is an expected outcome because the fluid removed contributes to body weight. This finding reflects the therapeutic effect of the procedure and is not a sign of complication.

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Correct Answer is A

Explanation

Rationale:

A. Lactulose is used to treat hepatic encephalopathy by reducing ammonia levels in clients with liver failure. However, in a client admitted with hypovolemic shock from active upper gastrointestinal bleeding, the priority is stabilizing circulation and airway, not administering medications for encephalopathy. Lactulose can worsen dehydration and diarrhea, potentially exacerbating hypovolemia, which is dangerous in a client already in shock. Therefore, this is not an appropriate immediate intervention.

B. For clients with esophageal varices, a balloon tamponade (e.g., Sengstaken-Blakemore tube) may be used to control bleeding. Monitoring balloon placement and duration is critical to prevent tissue necrosis, airway obstruction, or further complications. This is an appropriate intervention.

C. Airway management is critical in a client with an esophagogastric balloon tube and hypovolemic shock. Monitoring respiratory status ensures early detection of airway compromise, while neurological monitoring helps detect hypoperfusion or hypoxia. This is an appropriate and high-priority intervention.

D. If bleeding cannot be controlled with medical therapy or balloon tamponade, emergent surgical or interventional radiology procedures (e.g., variceal ligation or shunt procedures) may be necessary. Preparing for surgery is appropriate in severe, uncontrolled bleeding.

A. Obtain a culture of the drainage B. Clean the insertion site and redress the area. C. Check the client's temperature. D. Document the findings in the chart

Correct Answer is C

Explanation

Rationale:

A. While obtaining a culture may be indicated if infection is suspected, this is not the first action. The nurse must first assess the client for signs of systemic infection before taking any samples. Cultures will be guided by clinical findings such as fever, chills, or elevated white blood cell count.

B. Cleaning and redressing the site is part of standard care, but if the client is showing signs of infection (e.g., fever, elevated heart rate), immediate assessment of systemic involvement takes priority over routine site care.

C. The presence of yellow drainage around a central line catheter may indicate local infection, and fever could indicate systemic infection or sepsis, a life-threatening complication in clients receiving TPN. According to priority frameworks (ABCs and Maslow’s hierarchy), assessing for signs of infection or sepsis takes precedence before taking further steps like cultures or cleaning.

D. Documentation is important, but it is secondary to assessing for immediate threats to the client’s health. First, the nurse must determine whether the client is experiencing systemic infection.

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The nurse assists a health care provider with a paracentesis that removed 2000 mL of fluid for a client with ascites. Which finding is the greatest concern?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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