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?
Confirm that the client is able to urinate.
Compare the client's current weight with preprocedure weight.
Examine for leakage at the site of the procedure.
Check the client's serum albumin levels.
The Correct Answer is B
A. While urine output is important, it is not the most direct indicator of the success of a paracentesis.
B. Comparing the client's weight before and after the procedure helps to evaluate the effectiveness by showing a reduction in fluid buildup.
C. Leakage at the site could indicate a complication, but it is not the primary measure of the procedure’s
effectiveness.
D. Serum albumin levels may be monitored but are not the first indicator of success after a paracentesis.
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Related Questions
Correct Answer is C
Explanation
A. Preparing the client for an MRI is not the first step; assessment of neurological status is the priority.
B. Inserting an indwelling urinary catheter is unnecessary unless indicated after further assessment.
C. Determining the Glasgow Coma Scale score is the most important initial step to assess the client's neurological status and guide further interventions.
D. Administering mannitol is appropriate for increased intracranial pressure but should only be done after assessing the client's neurological condition.
Correct Answer is B
Explanation
A. Encouraging the client to watch television might distract them, but it does not provide the comfort and reassurance needed during a panic attack.
B. Sitting with the client provides a sense of security and reassurance, helping them feel safe during a panic attack. It is essential to stay calm and supportive.
C. Atomoxetine is a medication for ADHD and would not be appropriate for managing anxiety during a panic attack.
D. Teaching the client how to meditate is helpful in the long term but is not the most immediate and effective intervention during a panic attack.
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