A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

Every 5 minutes for 30 minutes, then every 4 hours thereafter.

Every 5 minutes for one hour.

Every 15 minutes for one hour, then every 1 hour for 2 hours.

Every 1 hour for 2 hours.

Answer and Explanation

The Correct Answer is A

A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.

B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and

may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring

initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

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Correct Answer is C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

A. Keep diabetic medication on schedule as prescribed. B. Limit maximum daily fat intake to 15% of total calories. C. Check blood sugar levels every four to six hours every day. D. Restrict alcoholic beverages to no more than 1-2 per week.

Correct Answer is A

Explanation

A. Keep diabetic medication on schedule as prescribed.

This is the correct answer because maintaining a regular schedule for diabetic medication is crucial for managing blood glucose levels and preventing complications.

B. Limit maximum daily fat intake to 15% of total calories.

While reducing fat intake can be beneficial for overall health, it is not directly related to managing acute blood glucose levels or preventing immediate complications of diabetes.

C. Check blood sugar levels every four to six hours every day.

Frequent monitoring of blood sugar levels is important, but checking every four to six hours may not be necessary for all clients, especially if they are not on insulin or if their diabetes is well-controlled. It depends on individual needs and physician recommendations.

D. Restrict alcoholic beverages to no more than 1-2 per week.

Limiting alcohol intake is good advice for overall health and diabetes management, but it is not the most critical action compared to keeping medications on schedule to prevent complications.

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A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

Correct Answer is C

Explanation

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

Correct Answer is A

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

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The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

After receiving report, the nurse can most safely plan to assess which client last?