Which method is best for the practical nurse (PN) to use in determining early development of ascites in the client?

Rationale:

A. Position the client on the left side and reassess: Placing the client in the left lateral decubitus position shifts the heart closer to the chest wall, making the PMI easier to palpate, especially in older adults or clients with a thick chest wall. This maneuver is a standard initial approach to improve assessment accuracy before concluding that the apical site is non-palpable.

B. Document the lack of an apical pulse in the medical record: Recording a missing apical impulse without further assessment is premature. The inability to palpate the PMI in the supine position can be influenced by positioning or body habitus, additional assessment techniques should be attempted first.

C. Assess the client for signs of diminished cardiac output: While important for overall cardiac assessment, evaluating for symptoms such as hypotension, fatigue, or altered mentation does not address the immediate issue of locating the PMI. This action is supportive but not the priority initial step.

D. Count the pulse rate and volume at the radial site: Measuring the radial pulse provides information on peripheral perfusion but does not substitute for assessing the apical impulse, which is critical for detecting dysrhythmias or confirming heart rate and rhythm, particularly in a bedfast client.

Rationale:

A. Hemoglobin: Melena indicates upper gastrointestinal bleeding, which can result in significant blood loss. Monitoring hemoglobin levels allows the nurse to detect anemia and quantify the impact of blood loss on the client’s oxygen-carrying capacity. Decreasing hemoglobin is a critical marker for assessing the severity of bleeding and guiding interventions such as transfusion.

B. Blood urea nitrogen (BUN): While BUN can rise with gastrointestinal bleeding due to the digestion of hemoglobin, it is not as specific or immediate an indicator as hemoglobin. BUN elevation may provide supporting information but does not replace direct monitoring of hemoglobin for safety and treatment decisions.

C. White blood cells (WBC): WBC count reflects infection or inflammation but is not directly influenced by gastrointestinal bleeding. Monitoring WBC does not provide relevant information for assessing the acute consequences of melena.

D. Glucose: Blood glucose levels are unrelated to melena or gastrointestinal bleeding. Glucose monitoring is not indicated in this context unless the client has a comorbid condition such as diabetes that requires routine assessment.