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 B
Explanation
A. Social worker. While a social worker can assist with emotional or financial concerns, they are not involved in managing oxygen delivery systems or therapy adherence related to medical devices.
B. Respiratory therapist. The respiratory therapist is the most appropriate team member to consult regarding oxygen delivery methods. They can assess the client’s needs, explain alternatives (e.g., nasal cannula instead of a mask), and help promote comfort and compliance with therapy.
C. Assistive personnel. Assistive personnel can support basic care tasks, but they are not trained to adjust or manage oxygen therapy or address client concerns about medical treatments.
D. Occupational therapist. Occupational therapists assist clients in regaining independence with daily activities, not in managing oxygen therapy. This issue is outside their scope of practice.
Correct Answer is B
Explanation
A. A client who has a fracture and is in balance suspension traction. This client is non-ambulatory and difficult to move quickly, so should not be evacuated first unless they are in immediate danger. They would require additional assistance and equipment to move safely.
B. A client who is ambulatory and receiving oxygen. This client is able to walk independently and can evacuate with minimal assistance, even while on oxygen. Evacuating ambulatory clients first helps clear the area quickly and frees up staff to assist less mobile clients.
C. A client who uses a wheelchair and is confused. While this client needs help due to confusion and mobility limitations, they are not the priority for first evacuation unless in immediate danger. They require more time and assistance.
D. A client who is bedridden and wears a hearing aid. This client is non-ambulatory and may have communication challenges, which makes evacuation more complex. They would be evacuated after ambulatory clients for safety and efficiency.
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