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Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client with severe hepatic cirrhosis who recently underwent a therapeutic bedside paracentesis with the removal of 5 liters of ascitic fluid. Twenty minutes after the procedure, the client reports feeling dizzy and nauseous. The nurse observes that the client's heart rate has increased from 78 to 118 beats per minute, and the blood pressure has decreased from 132/82 mm Hg to 94/56 mm Hg. Which of the following actions should the nurse perform first to mitigate the risk of severe hemodynamic collapse?

  1. Initiate the prescribed intravenous infusion of albumin.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position.
  3. C
    Document the vital signs as an expected physiological fluid shift response.
  4. D
    Assign the unlicensed assistive personnel to obtain vital signs every 15 minutes.

Cevap

The most critical action is to initiate the prescribed intravenous infusion of albumin.
The removal of large volumes of ascitic fluid decreases abdominal pressure, leading to splanchnic vasodilation and a massive shift of intravascular fluid back into the peritoneal cavity. The client's symptoms of dizziness, accompanied by tachycardia and hypotension, are classic indicators of impending hypovolemic shock. Administering a colloid volume expander, such as intravenous albumin, increases intravascular oncotic pressure. This pulls fluid back into the bloodstream, restoring cardiac output and mitigating the risk of cardiovascular collapse.

Adım Adım Çözüm

1
Analyze the client's vital sign trends and reported symptoms following the invasive procedure.
The acute onset of dizziness, marked tachycardia, and significant hypotension indicate a severe decrease in intravascular volume.
Large-volume paracentesis decreases intra-abdominal pressure, causing rapid vasodilation and a massive shift of fluid from the intravascular space into the peritoneal cavity.
2
Identify the immediate priority to prevent profound hypovolemic shock.
The primary goal is to restore intravascular volume and maintain organ perfusion.
Without intervention, the fluid shift will lead to progressive hemodynamic collapse and potential organ failure.
3
Select the specific intervention that addresses the underlying pathophysiological mechanism.
Administering intravenous albumin is the correct choice.
Albumin acts as a colloid, increasing plasma oncotic pressure to pull fluid back into the vascular space, effectively reversing the procedure-induced hypovolemia.

Anahtar Kavram

Post-paracentesis hypovolemic shock recognition and volume replacement
Tahmini Süre:1m 15s
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Konular

Reduction of Risk Potential

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