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Difficulty: MediumReduction of Risk Potential

A client with hepatic cirrhosis is recovering on the medical-surgical unit 30 minutes after a bedside paracentesis, during which 3.5 liters of ascitic fluid was removed. The client suddenly reports feeling dizzy and lightheaded. The nurse assesses a heart rate of 118 bpm, a blood pressure of 86/54 mmHg, and a respiratory rate of 18/min. Which action should the nurse take immediately to reduce the client's risk of severe circulatory compromise?

  1. Place the client in a supine position and elevate the lower extremities.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to promote oxygenation.
  3. C
    Document the vital signs as an expected physiological response to fluid removal.
  4. D
    Prepare to obtain an arterial blood gas sample to evaluate for respiratory alkalosis.

Answer

Place the client in a supine position and elevate the lower extremities.
The client is experiencing early signs of hypovolemic shock due to rapid fluid shifts from the intravascular space into the peritoneal cavity following the removal of a large volume of ascitic fluid. Placing the client in a supine position with the lower extremities elevated (modified Trendelenburg) utilizes gravity to promote venous return to the heart and immediately increases cerebral perfusion, which is the priority to mitigate circulatory collapse.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client is tachycardic, hypotensive, and dizzy 30 minutes after the removal of a large volume (3.5 liters) of fluid.
Identifying abnormal trends is necessary to detect post-procedure complications early.
2
Determine the underlying pathophysiology.
The findings indicate hypovolemic shock caused by rapid fluid shifts from the intravascular space into the peritoneal cavity following the paracentesis.
Understanding the cause directs the appropriate, life-saving nursing intervention.
3
Select the immediate priority action.
The nurse must improve venous return and cerebral perfusion by placing the client supine with elevated legs.
This physical positioning maneuver rapidly increases blood flow to vital organs before pharmacological volume expansion (like IV albumin) can be initiated.

Key Concept

Early recognition and immediate positioning for hypovolemic shock post-paracentesis.
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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