Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

The client's albumin level is increased.

The client's platelet count is normal.

The dressing has a 2-cm area of serous drainage.

The client's heart rate is 122 beats/min.

Answer and Explanation

The Correct Answer is D

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Deep vein thrombosis is a condition where blood clots form in the deep veins, usually in the legs. While it is a serious condition, it is not directly associated with portal hypertension in patients with late-stage cirrhosis. Portal hypertension primarily affects the liver and its associated blood vessels, leading to complications within the portal circulation system rather than systemic venous thrombosis.

Choice B reason: Ascites is the accumulation of fluid in the abdominal cavity, and it is a common complication of portal hypertension in patients with cirrhosis. Increased pressure in the portal vein leads to leakage of fluid into the abdominal cavity, causing distension and discomfort. Ascites can significantly impact the patient's quality of life and requires careful management.

Choice C reason: Splenomegaly, or enlargement of the spleen, is another potential complication of portal hypertension. The increased pressure in the portal vein can cause blood to back up into the spleen, leading to its enlargement. Splenomegaly can result in hypersplenism, where the spleen becomes overactive and destroys blood cells, contributing to anemia, thrombocytopenia, and leukopenia.

Choice D reason: Esophageal varices are dilated blood vessels in the esophagus that develop as a result of portal hypertension. The increased pressure in the portal vein causes blood to divert through collateral vessels, including those in the esophagus. These varices can rupture and cause life-threatening bleeding, making them a critical complication to monitor in patients with cirrhosis.

Choice E reason: Increased platelet levels are not typically seen in patients with portal hypertension. In fact, portal hypertension and cirrhosis often lead to thrombocytopenia, or low platelet levels, due to splenic sequestration and reduced platelet production. Thrombocytopenia is a more common finding in this patient population.

A. I must stop halfway up the stairs to catch my breath. B. I am awakened by the need to urinate at night. C. I have been drinking more water than usual. D. I have experienced blurred vision on several occasions.

Correct Answer is A

Explanation

Choice A reason: The statement "I must stop halfway up the stairs to catch my breath" is a significant indicator of left-sided heart failure. Left-sided heart failure leads to pulmonary congestion, resulting in symptoms such as shortness of breath, especially during physical activities. This occurs because the heart is unable to effectively pump blood to the body, causing fluid buildup in the lungs and leading to exertional dyspnea.

Choice B reason: The statement "I am awakened by the need to urinate at night" refers to nocturia, which can be associated with heart failure but is not as specific to left-sided heart failure as exertional dyspnea. Nocturia can occur due to fluid redistribution when lying down, but it is not a definitive sign of left-sided heart failure alone.

Choice C reason: The statement "I have been drinking more water than usual" is not directly related to left-sided heart failure. Increased water intake could be indicative of other conditions such as diabetes or dehydration, but it is not a specific symptom of left-sided heart failure.

Choice D reason: The statement "I have experienced blurred vision on several occasions" is not typically associated with left-sided heart failure. Blurred vision can result from various causes, including visual disturbances, blood pressure changes, or other medical conditions, but it is not a hallmark symptom of left-sided heart failure.

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Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with late-stage cirrhosis develops portal hypertension. All of the following are potential complications that can develop from this condition. Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

Correct Answer is A

Explanation

Which instruction would best reduce the symptoms of a client with heart failure and assure more comfort at home?

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