A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?
Place the client in a side-lying position for the procedure.
Administer a low-volume hypertonic enema the night before the procedure.
Weigh the client before and after the procedure.
Ensure the client has a full bladder just prior to the procedure.
The Correct Answer is C
A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
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Related Questions
Correct Answer is D
Explanation
A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." The breast is rarely fully emptied during a feeding. Infants should be allowed to feed on one side until they naturally release it, ensuring they receive the nutrient-rich hindmilk.
B. "Manually expressing my milk will decrease my milk supply." Manual expression, like breastfeeding, stimulates milk production. Regularly removing milk from the breasts actually helps maintain or increase supply, especially during periods of engorgement or separation.
C. “My baby should always start on the same breast when feeding.” Alternating the starting breast with each feeding ensures even stimulation and drainage of both breasts. Always starting on the same side could lead to engorgement or reduced supply in the unused breast.
D. “The more my baby is at the breast sucking the more milk I will produce.” Breast milk production is based on a supply and demand mechanism. The more frequently and effectively the baby nurses, the more milk the body is signaled to produce.
Correct Answer is C
Explanation
A. Educating clients about contraindications to specific immunizations. This is an example of primary prevention, which aims to prevent disease before it occurs by promoting safe practices and avoiding harmful exposures.
B. Providing clients with information about the benefits of exercise. This also falls under primary prevention, as it promotes a healthy lifestyle to prevent the onset of disease or complications.
C. Using an electronic messaging system to remind clients when to take medications. This is an example of tertiary prevention, which focuses on managing chronic conditions (like HIV) and preventing complications or progression of the disease through adherence support.
D. Helping clients understand health screenings covered by their insurance plans. This is considered secondary prevention, which involves early detection and prompt intervention to catch diseases in the early stages through screenings.
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