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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is monitoring an adult client who underwent a large-volume therapeutic paracentesis 22 hours ago. The client's baseline blood pressure was 138/82138/82 mm Hg and heart rate was 7676 beats/min. The client now reports mild lightheadedness and nausea. The PN notes the client's skin is slightly pale and cool. Current vital signs are: blood pressure 102/68102/68 mm Hg, heart rate 108108 beats/min, and respiratory rate 2020 breaths/min. The abdominal dressing is dry and intact. Which of the following is the priority nursing action?

  1. Place the client in a supine position and immediately notify the registered nurse.Answer
  2. B
    Administer a prescribed PRN oral antiemetic for the client's nausea.
  3. C
    Document the vital signs and reassess in one hour, as this is an expected physiological response.
  4. D
    Assist the client into a high-Fowler's position to promote optimal lung expansion and comfort.

Answer

The priority action is to place the client in a supine position and immediately notify the registered nurse.
Although the client's systolic blood pressure is technically above 100100 mm Hg, it represents a significant drop from the baseline. This drop, accompanied by tachycardia, pallor, and lightheadedness, indicates early, subtle hypovolemic shock caused by intravascular fluid shifts following large-volume fluid removal. The priority is to maximize venous return to the vital organs by placing the client flat (supine) and to immediately escalate these critical findings to the registered nurse for rapid emergency intervention.

Step-by-Step Solution

1
Analyze the client's current clinical presentation and compare it to baseline findings.
The client has a significant drop in blood pressure (from 138/82138/82 to 102/68102/68 mm Hg), tachycardia (108108 beats/min), pallor, and lightheadedness.
Identifying changes from baseline is essential to recognize developing complications rather than relying solely on absolute numeric thresholds.
2
Interpret the clinical significance of these assessment findings.
The findings indicate early hypovolemic shock resulting from rapid intravascular fluid shifts, a known complication of large-volume fluid removal.
Recognizing the pathophysiology of the complication determines the urgency of the response.
3
Determine the priority nursing action based on the airway, breathing, circulation (ABC) framework.
The priority is addressing the circulation deficit. The PN must maximize venous return by placing the client flat and immediately escalate to the RN.
Immediate physical intervention (positioning) and escalation are required to prevent severe cardiovascular collapse.

Key Concept

Hypovolemic Shock Recognition and Escalation Post-Paracentesis
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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