A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:

Correct Answer: C

Rationale: Following a paracentesis procedure where a large amount of ascitic fluid is removed, there is a risk of developing a fluid shift and a potential complication known as "paracentesis-induced circulatory dysfunction" (PICD). This may cause a sudden increase in central blood volume due to rapid re-distribution of fluid, leading to respiratory congestion, dyspnea, and hypoxemia. Therefore, it is crucial for the nurse to monitor the client closely for signs of respiratory distress or congestion immediately after the procedure to prevent any respiratory complications. A rapid, thready pulse (choice A) may indicate hypovolemia, but it is not the most important immediate concern in this case. Decreased peristalsis (choice B) and an increased temperature (choice D) are not typically associated with the immediate post-paracentesis period and are therefore lower priorities compared to monitoring for signs of respiratory congestion.

Correct Answer: B

Rationale: The IV route was likely chosen for the administration of furosemide (Lasix) in this acutely fluid-overloaded patient because IV is the route of choice when rapid administration is needed. When given intravenously, the medication is able to produce a quicker and more immediate diuretic effect compared to oral administration, allowing for more rapid relief of fluid overload symptoms. This can be crucial in emergency situations where the patient's condition requires fast intervention.

Correct Answer: A

Rationale: The presence of white patches on the tonsils is a visual sign that may be revealed by a visual examination in a client with a tonsillar infection caused by group A streptococci. These white patches are known as exudates and can be a characteristic feature of streptococcal tonsillitis. These exudates may range in appearance from small white spots to larger patches that cover the tonsils. Additionally, other signs commonly associated with streptococcal tonsillitis may include swollen and red tonsils, fever, sore throat, and sometimes swollen lymph nodes in the neck. It is important to note that definitive diagnosis often requires laboratory testing such as a rapid strep test or throat culture to confirm the presence of group A streptococci.

Correct Answer: A

Rationale: Nosocomial pneumonia occurs in a healthcare setting. It is a type of pneumonia that is contracted during a hospital stay or other healthcare facilities. The risk of developing nosocomial pneumonia is higher in patients who are already hospitalized due to various medical conditions, surgeries, or use of medical devices like ventilators. The infection can be caused by different types of bacteria, viruses, or fungi present in the healthcare environment. Preventive measures, such as proper hand hygiene, infection control practices, and minimizing the use of invasive devices, are crucial in reducing the incidence of nosocomial pneumonia.

Correct Answer: B

Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.