A nurse is monitoring a client with severe hepatic cirrhosis who is undergoing a large-volume therapeutic paracentesis. After 3.5 liters of ascitic fluid have been drained, the client reports sudden dizziness and nausea. The client's heart rate increases from 82 to 124 beats per minute, and the blood pressure drops from 130/84 mm Hg to 92/58 mm Hg. Which action should the nurse take first to reduce the risk of further physiological deterioration?
- Clamp the drainage tubing immediately to stop further fluid removal.Cevap
- BTransition the client into an upright sitting position to alleviate the nausea.
- CAllow the drainage to continue while reassuring the client about procedural anxiety.
- DObtain a sample for arterial blood gas analysis to evaluate for metabolic acidosis.
Cevap
Clamp the drainage tubing immediately to stop further fluid removal.
The correct action directly addresses the root cause of the client's hemodynamic instability. Rapid removal of large volumes of ascitic fluid can lead to a sudden shift of fluid from the intravascular space into the peritoneal cavity, causing hypovolemia and shock. Clamping the tube immediately stops this process, preventing further cardiovascular collapse.
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Anahtar Kavram
Paracentesis-Induced Circulatory Dysfunction and Hypovolemic Shock