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 C

A. Monitoring every 5 minutes for 30 minutes then every 4 hours is not sufficiently structured for ongoing early detection of delayed hypotension after significant fluid removal.

B. Monitoring every 5 minutes for one hour may be unnecessarily frequent for a stable post-paracentesis client and does not provide appropriate step-down surveillance beyond the first hour.

C. Monitoring every 15 minutes for one hour allows close observation during the highest-risk period immediately after the procedure, followed by every 1 hour for 2 hours to continue surveillance as the client stabilizes. This schedule aligns with standard post-paracentesis monitoring for potential hypotension and fluid shifts.

D. Monitoring every 1 hour for 2 hours alone is insufficient in the immediate post-procedure phase, as it does not provide close enough observation during the highest risk period.

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Correct Answer is B

Explanation

A. Guide in moving the non-affected limb to override the sensation being experienced.
Encouraging movement of the non-affected limb may not effectively address phantom limb pain and could potentially exacerbate discomfort or distress.

B. Reassure that this can be a normal postsurgical sensation.
Phantom limb pain is a common phenomenon after amputation surgeries. Providing reassurance that this sensation is normal can help alleviate anxiety and provide comfort to the adolescent.

C. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.
While a prosthetic limb and physical therapy can help in the long term, they may not immediately address the phantom limb pain experienced in the early postoperative period.

D. Explain that the sensations of tingling and pain are not real.
Invalidating the adolescent's experience of phantom limb pain by suggesting that the sensations are not real may worsen distress and anxiety. It's essential to acknowledge the client's experience and provide supportive care.

A. Redress the abdominal incision. B. Leave the lights on in the room at night. C. Apply soft bilateral wrist restraints. D. Replace the IV site with a smaller gauge. E. None F. None

Correct Answer is A

Explanation

A. Redress the abdominal incision The client's abdominal dressing is no longer occlusive, which exposes the surgical wound to potential contamination and infection. The nurse must immediately cleanse and redress the incision to protect it. While the client may try to pick at it again, maintaining wound integrity is the priority clinical intervention.

B. Leave the lights on in the room at night Leaving bright lights on at night can disrupt the client's circadian rhythm, worsen sleep deprivation, and increase confusion or sundowning behaviors. A dim nightlight is a better alternative to provide orientation without causing sensory overload or sleep disruption.

C. Apply soft bilateral wrist restraints Restraints are a restrictive measure that should only be used as a last resort after all non-pharmacological and behavioral interventions have failed. In clients with dementia, physical restraints often escalate agitation, increase confusion, and pose significant safety risks such as skin breakdown or entanglement.

D. Replace the IV site with a smaller gauge The IV insertion site is described as pink, which indicates early signs of irritation or phlebitis. Changing the gauge of the catheter at the current site does not resolve the inflammation or protect the line from being pulled. The IV needs to be monitored, protected, or discontinued/relocated if phlebitis progresses, but changing the gauge is not the solution.

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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

The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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