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 ["A","D"]
Explanation
A. Medicaid. Medicaid provides health coverage for low-income individuals, including young adults who meet poverty guidelines. It can cover home health services and IV therapy, making it an appropriate resource for this client.
B. Medicare Part A. Medicare Part A generally covers hospital care and limited home health services, but it is primarily for individuals aged 65 and older or those with certain disabilities. It is not typically available to young adults without qualifying conditions.
C. Respite care. Respite care provides temporary relief to caregivers, not direct services for clients requiring IV therapy. It is more relevant for individuals with long-term caregiving needs, not this scenario.
D. Food stamps. Also known as the Supplemental Nutrition Assistance Program (SNAP), food stamps assist low-income individuals in accessing food. It’s a valuable support service for someone living below the poverty line.
E. Adult day care. This is intended for older adults or individuals with disabilities who need supervision during the day. It is not applicable for a young adult requiring home IV therapy.
Correct Answer is C
Explanation
A. Hyperthyroidism. This condition is not a contraindication to the use of combination oral contraceptives. Women with hyperthyroidism can generally use hormonal contraceptives safely under medical supervision.
B. Hypocalcemia. Low calcium levels are not linked to increased risk with combination oral contraceptives and do not contraindicate their use.
C. Thrombophlebitis. This condition involves inflammation and clot formation in the veins, and is a major contraindication to combination oral contraceptives. These medications increase the risk of blood clots, making them unsafe for clients with current or prior thromboembolic disorders.
D. Diverticulosis. This gastrointestinal condition is not affected by hormone levels and is not a contraindication to combination oral contraceptive use.
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