A client had a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?
a. Urine output of 20 mL/hr
b. Systolic blood pressure increase of 10 mm Hg
c. Respiratory rate drop from 18 to 14
d. A 3-pound drop in weight
A
Rapid removal of ascitic fluid causes decreased abdominal pressure, which can contribute to hy-povolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. The nurse would expect the client's weight to drop as fluid is removed. A decrease in respiratory rate indi-cates that breathing has been made easier by the procedure. A slight increase in systolic blood pressure is insignificant.
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