The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness.
Following a paracentesis, the nurse receives laboratory results of the ascitic fluid that show the polymorphonuclear leukocyte count is 425/mm (0.42 x 10/L). After notifying the healthcare provider, what action should the nurse take next?
Review serum protein levels
Begin abdominal girth measurements
Initiate antibiotic therapy
Assess neurological status
The Correct Answer is C
Choice A rationale
Reviewing serum protein levels can provide valuable information about a client’s nutritional status and liver function. However, in the context of a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness, and has a high polymorphonuclear leukocyte count in ascitic fluid, initiating antibiotic therapy is the priority.
Choice B rationale
Beginning abdominal girth measurements can be useful for monitoring the progression of ascites in a client with liver disease. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
Choice C rationale
Initiating antibiotic therapy is the correct intervention in this case. The client’s symptoms and the high polymorphonuclear leukocyte count in the ascitic fluid suggest spontaneous bacterial peritonitis, a serious complication of cirrhosis that requires immediate antibiotic treatment.
Choice D rationale
Assessing neurological status is important in clients with liver disease, as they are at risk for hepatic encephalopathy. However, in this scenario, the priority is to treat the potential infection indicated by the client’s symptoms and lab results.
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Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the patient’s joint pain, it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice B rationale
Infusing an intravenous fluid bolus is the first intervention that should be implemented in an acute adrenal crisis. This can help to increase the patient’s blood pressure, which is dangerously low.
Choice C rationale
Administering a PRN oral antipyretic could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
Choice D rationale
Covering the patient with a cooling blanket could help to reduce the patient’s fever, but it is not the first intervention that should be implemented in an acute adrenal crisis. The patient’s low blood pressure and high heart rate are immediate life-threatening conditions that need to be addressed first.
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