An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.

He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.

In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.

Choice A rationale
Monitoring the patient’s blood pressure every 1 hour for 2 hours after paracentesis may not be sufficient. Paracentesis is a procedure to remove fluid that has accumulated in the abdominal cavity (a condition called ascites). This is a common problem in people with certain diseases, including liver and kidney disease. Changes in blood pressure can occur rapidly after this procedure, so more frequent monitoring is needed immediately after the procedure.
Choice B rationale
Monitoring the patient’s blood pressure every 5 minutes for one hour after paracentesis may be too frequent and could cause unnecessary stress for the patient. It is important to balance the need for monitoring with the patient’s comfort and well-being.
Choice C rationale
Monitoring the patient’s blood pressure every 15 minutes for one hour, then every 1 hour for 2 hours after paracentesis is a good schedule. This allows for close monitoring immediately after the procedure, when complications are most likely to occur. It then allows for continued monitoring as the patient stabilizes.
Choice D rationale
Monitoring the patient’s blood pressure every 5 minutes for 30 minutes, then every 4 hours thereafter may not provide enough monitoring in the immediate post-procedure period. While it is important to continue monitoring, the first few hours after the procedure are a critical time when complications are most likely to occur.

Choice A rationale

Nadolol is a beta-blocker that can decrease heart rate and contractility, which can potentially exacerbate heart failure and lead to cardiogenic shock.

Choice B rationale

Captopril is an angiotensin-converting enzyme (ACE) inhibitor that is often used in the treatment of heart failure. It works by relaxing blood vessels and reducing the workload of the heart.

Choice C rationale

Digoxin is a cardiac glycoside that is used to treat heart failure and certain heart arrhythmias. It works by increasing the force of the heart’s contractions, which can improve heart function.

Choice D rationale

Hydrochlorothiazide is a diuretic that is often used in the treatment of heart failure. It works by helping the body get rid of excess fluid, which can reduce the workload of the heart.