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A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?

A) Urine output via indwelling urinary catheter is 20 mL/hr
B) Blood pressure increases from 110/58 to 120/62 mm Hg
C) Respiratory rate decreases from 18 to 14 breaths/min
D) A decrease in the client's weight by 6 kg

1 Answer

4 votes

Final answer:

The urine output of 20 mL/hr post-paracentesis is concerning and requires action by the nurse, as it indicates possible low urine output which could lead to serious complications. Blood pressure and respiratory rate changes are within normal ranges and significant weight loss is expected following the procedure.

Step-by-step explanation:

The student's question concerns a nurse assessing a post-paracentesis client. The specific assessment finding that requires action by the nurse is A) Urine output via indwelling urinary catheter is 20 mL/hr. This is significantly less than the normal urine output of 0.5-1 mL/kg/hr, which, for an average adult, would usually amount to at least 30-40 mL/hr. Such low urine output could signal potential complications such as hypovolemia, especially after a procedure such as paracentesis that can remove large volumes of fluid from the body. The nurse should address this situation promptly, possibly by evaluating the client for signs of low blood volume or other complications, and reporting the finding to the healthcare provider.

Options B) and C) describe variations within normal ranges for blood pressure and respiratory rate, respectively, and therefore would not typically require immediate action. The significant weight loss, option D), although noteworthy, is expected after paracentesis, which is done to remove excess fluid in the abdomen.

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