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
ANS: A
Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.
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