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Difficulty: HardReduction of Risk Potential

A practical nurse is providing care for a client with hepatic cirrhosis who underwent a therapeutic paracentesis for severe ascites three hours prior. The nurse reviews the client's current clinical data compared to baseline:

ParameterPre-Procedure BaselineCurrent Assessment
Heart Rate82 beats/min118 beats/min
Blood Pressure134/78 mm Hg92/56 mm Hg
Hemoglobin11.4 g/dL8.8 g/dL

Based on these findings, which action is the priority for the nurse to perform?

  1. A
    Log the physiological parameters in the flowsheet as a normal consequence of fluid extraction.
  2. B
    Place the laboratory report in the physical chart for provider review during the next scheduled rounds.
  3. Directly communicate the downward trends in hemodynamics and laboratory values to the charge nurse.Answer
  4. D
    Accept delegation to independently spike and regulate an ordered transfusion of packed red blood cells.

Answer

The priority action is to directly communicate the downward trends in hemodynamics and laboratory values to the charge nurse.
The correct action involves immediately reporting the findings. The combination of marked tachycardia, hypotension, and a dropping hemoglobin level following an invasive procedure strongly indicates active internal bleeding or hypovolemic shock. This requires urgent medical intervention beyond the practical nurse's independent scope of practice.

Step-by-Step Solution

1
Analyze the client's clinical data in the context of the recent paracentesis procedure.
The client exhibits significant tachycardia (118 beats/min), hypotension (92/56 mm Hg), and a sharp drop in hemoglobin (11.4 to 8.8 g/dL).
Identifying deviations from expected post-procedure baselines is the first step in risk reduction.
2
Synthesize the findings to determine the underlying physiological risk.
The combined findings strongly suggest active internal bleeding resulting in hypovolemic shock, a life-threatening complication of the procedure.
Recognizing the clinical pattern of shock is essential for determining the urgency of the situation.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The priority is to escalate these critical findings immediately so life-saving medical interventions can be initiated.
Practical nurses must promptly report life-threatening changes to the registered nurse or healthcare provider to ensure patient safety.

Key Concept

Early recognition and escalation of post-procedural hypovolemic shock
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Topics

Reduction of Risk Potential

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