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 D

Explanation

A. A blood glucose level of 90 mg/dL is within the normal reference range of 74 to 106 mg/dL, so it is not a concern.
B. A potassium level of 4 mEq/L is also within the normal reference range of 3.5 to 5.0 mEq/L, so it does not need to be reported.
C. Although the hemoglobin level of 13 g/dL is below the reference range provided, it is not critically low and may not be urgent unless the patient has symptoms of anemia or other related issues.
D. A serum creatinine level of 5 mg/dL is significantly higher than the normal reference range of 0.5 to 1.1 mg/dL. This indicates renal impairment, which could affect the patient's ability to clear medications used during surgery and could lead to postoperative complications. Therefore, it is crucial to report this finding to the surgeon immediately.

A. Provide only distilled water. B. Document abdominal girth. C. Offer a high protein diet. D. Use a cushion when sitting.

Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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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

Correct Answer is D

Explanation

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

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