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Difficulty: HardPhysiological Adaptation

Two hours following a large-volume paracentesis for the management of ascites, a client suddenly becomes increasingly restless. The assigned practical nurse obtains vital signs revealing a blood pressure of 92/54 mm Hg and an apical pulse of 118 beats per minute. Which of the following actions should the nurse prioritize? Select all that apply.

  1. Notify the registered nurse immediately regarding the changes in the client's conditionAnswer
  2. B
    Administer the prescribed as-needed oral opioid analgesic to alleviate the client's restlessness
  3. C
    Elevate the head of the bed to a high-Fowler's position to facilitate respiratory expansion
  4. Assist the registered nurse in preparing equipment for the administration of intravenous albuminAnswer
  5. E
    Document the vital sign changes as an expected physiological response to fluid removal
  6. Apply a pulse oximeter to obtain a current oxygen saturation readingAnswer

Answer

The correct actions are to notify the registered nurse immediately, assist in preparing for intravenous albumin administration, and apply a pulse oximeter to assess oxygenation.
The correct answers represent immediate, life-saving interventions within the practical nursing scope of practice for a client experiencing early hypovolemic shock. The client's presentation of restlessness, tachycardia, and hypotension following a large-volume paracentesis indicates post-paracentesis circulatory dysfunction. In this emergency scenario, the priority is to address airway, breathing, and circulation (ABCs). The nurse must immediately escalate the findings to the registered nurse, obtain additional circulatory and respiratory data by applying a pulse oximeter, and prepare to assist with volume replacement therapies, such as intravenous albumin, which restores intravascular volume and blood pressure.

Step-by-Step Solution

1
Analyze the client's current clinical presentation and vital signs.
The client has new-onset restlessness, hypotension (92/54 mm Hg), and tachycardia (118 bpm) shortly after a major fluid removal procedure.
Recognizing abnormal data is the foundational step in clinical judgment and prioritization.
2
Identify the underlying pathophysiological process occurring.
These findings indicate post-paracentesis circulatory dysfunction, a form of hypovolemic shock caused by rapid fluid shifts out of the intravascular space.
Connecting symptoms to the physiological adaptation failure determines the urgency of the situation.
3
Determine the priority nursing actions within the practical nursing scope of practice.
The nurse must immediately escalate the critical findings to the RN, gather additional ABC data (oxygen saturation), and prepare for volume expansion therapy.
Prompt intervention is required to prevent severe tissue hypoperfusion and cardiovascular collapse.

Key Concept

Post-Paracentesis Circulatory Dysfunction and Early Shock Recognition
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Topics

Physiological Adaptation

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