A nurse is caring for a client in the gastroenterology unit.
Absence of respiratory distress
Stable vital signs
Reduced ascitic fluid volume
Decreased abdominal pressure
Improved breathing
Relief of abdominal discomfort
Correct Answer : D,E,F
Rationale:
- Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
- Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
- Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
- Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
- Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. High-fiber foods are beneficial for bowel regularity and should not be decreased.
B. Excessive or chronic use of stimulant laxatives like bisacodyl can lead to electrolyte imbalances, dehydration, and dependence.
C. While rectal irritation is possible, electrolyte imbalance is the more significant risk.
D. Irregular bowel movements are common and not necessarily indicative of poor intestinal health.
Correct Answer is B
Explanation
Rationale:
A. Restlessness can occur with electrolyte imbalances or hypoxia, but it is not a hallmark of low albumin or protein malnutrition.
B. Low serum albumin and total protein decrease plasma oncotic pressure, allowing fluid to shift from the vascular space into interstitial tissues, leading to peripheral and sometimes generalized edema (anasarca).
C. Pallor is more indicative of anemia, which may coexist but is not a direct effect of hypoalbuminemia.
D. Confusion can result from electrolyte disturbances, hypoxia, or hepatic encephalopathy, but it is not a direct manifestation of low albumin.
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