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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client who underwent a large-volume paracentesis to relieve severe ascites 9090 minutes ago. The client suddenly reports profound dizziness and a feeling of impending doom. Current vital signs reveal a heart rate of 122122 beats per minute, a respiratory rate of 2424 breaths per minute, and a blood pressure of 84/5084/50 mm Hg. Which immediate action should the nurse perform?

  1. A
    Administer the client's scheduled daily dose of oral spironolactone.
  2. B
    Guide the client into a high Fowler's posture to maximize lung expansion.
  3. Position the client flat in bed while raising the lower extremities.Cevap
  4. D
    Begin a focused abdominal examination by deeply palpating the quadrants.

Cevap

The immediate priority is to support the client's circulation by positioning them flat with their lower extremities elevated.
The client is exhibiting classic signs of paracentesis-induced circulatory dysfunction (hypovolemic shock) caused by a rapid fluid shift after a large volume of fluid is removed. The priority action is to optimize venous return and cerebral perfusion. Positioning the client flat with the legs elevated (modified Trendelenburg) immediately uses gravity to divert blood from the lower extremities back to the central circulation, supporting blood pressure and cardiac output.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital signs following the invasive procedure.
The tachycardia (122122 bpm) and severe hypotension (84/5084/50 mm Hg), combined with dizziness, indicate acute hypovolemic shock.
Large-volume paracentesis can cause rapid fluid shifts from the intravascular space into the peritoneal cavity, leading to paracentesis-induced circulatory dysfunction.
2
Identify the highest priority nursing need using the airway, breathing, and circulation (ABC) framework.
The primary life-threatening issue is a severe deficit in circulation.
Inadequate circulating blood volume leads to decreased tissue perfusion and potential organ failure.
3
Select the most effective and immediate mechanical intervention to support the cardiovascular system.
Place the client in a modified Trendelenburg position (flat with legs elevated).
This positioning utilizes gravity to immediately divert venous blood from the lower extremities back to the heart, temporarily improving cardiac output and vital organ perfusion.

Anahtar Kavram

Management of Paracentesis-Induced Circulatory Dysfunction
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Konular

Reduction of Risk Potential

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