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Difficulty: MediumReduction of Risk Potential

An assigned client recently underwent a large-volume paracentesis for the management of ascites. Two hours following the procedure, the practical nurse records a blood pressure of 94/56 mmHg and a resting heart rate of 118 beats per minute. The client's pre-procedure baseline demonstrated a blood pressure of 134/82 mmHg and a heart rate of 74 beats per minute. Based on these findings, which action must the nurse take first?

  1. A
    Assist the client into a high Fowler's position to promote optimal lung expansion and comfort.
  2. B
    Document the vital signs in the chart as an anticipated physiological response to the fluid removal.
  3. Promptly report the altered vital signs to the supervising registered nurse for further evaluation.Answer
  4. D
    Independently initiate a rapid intravenous fluid bolus of normal saline to restore vascular volume.

Answer

The correct action is to promptly report the altered vital signs to the supervising registered nurse for further evaluation.
The client is exhibiting tachycardia and hypotension, which are early signs of hypovolemic shock due to rapid intravascular fluid shifts following a large-volume paracentesis. The most appropriate and immediate action within the practical nurse scope of practice is to communicate these unstable hemodynamic changes to the supervising registered nurse to ensure advanced assessment and treatment are rapidly initiated.

Step-by-Step Solution

1
Compare the client's current post-procedure vital signs to the pre-procedure baseline.
The blood pressure dropped significantly from 134/82 mmHg to 94/56 mmHg, and the heart rate increased from 74 to 118 beats per minute.
Identifying significant trends in vital signs is essential to recognize early postoperative complications.
2
Interpret the clinical significance of these sudden hemodynamic changes.
The findings of hypotension and tachycardia indicate a potential intravascular fluid shift or bleeding, which are early signs of hypovolemic shock.
Removal of a large amount of ascitic fluid during a paracentesis can cause rapid intravascular fluid shifts and decreased circulating volume.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The priority is to immediately escalate the critical findings to the registered nurse or healthcare provider.
The practical nurse must promptly report signs of hemodynamic instability so that advanced assessment and medical interventions can be initiated safely.

Key Concept

Recognizing early signs of hypovolemic shock (hypotension and tachycardia) post-paracentesis and taking appropriate action within the practical nurse scope of practice.
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Topics

Reduction of Risk Potential

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