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 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. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. B. An adult client with a rectal tube draining clear, pale red liquid drainage. C. An older client with a distended abdomen and no drainage from the nasogastric tube. D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac.

Correct Answer is A

Explanation

A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.

C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
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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

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

Correct Answer is A

Explanation

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?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

The nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement?