A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?
Compare the clients current weight with preprocedure weight.
Examine for leakage at the site of the procedure.
Check the client’s serum albumin levels.
Confirm that the client is able to urinate.
The Correct Answer is A
Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.
Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.
Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.
Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.
Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.
Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
Choice A is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
Choice B is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
Choice D is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status. However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Correct Answer is B
Explanation
The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.
Choice A rationale:
Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.
Choice B rationale:
Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.
Choice C rationale:
Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.
Choice D rationale:
Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.
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