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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. The client's behavior should be assessed more frequently (e.g., every 15-30 minutes) during seclusion to ensure their safety.
B. Documenting the client's behavior prior to seclusion helps provide a clear rationale for the decision and the need for the intervention.
C. Discussing inappropriate behavior is not appropriate while the client is in seclusion and may exacerbate agitation.
D. Fluids should be offered more frequently than every 2 hours during seclusion to ensure hydration and comfort.

A. Speak slowly when talking to the interpreter. B. Speak directly to the client. C. Pause in the middle of sentences. D. Use gestures to convey meaning.

Correct Answer is B

Explanation

A. Speaking slowly to the interpreter may cause delays in communication, but it does not enhance understanding. The interpreter is capable of processing normal speech speed.
B. The nurse should speak directly to the client, not the interpreter, to maintain rapport and respect. The interpreter will relay the information.
C. Pausing in the middle of sentences can disrupt the flow of conversation and make it harder for the interpreter to convey the message effectively.
D. Gestures should not be relied upon in place of clear verbal communication, as they can be misinterpreted and are culturally variable.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?

Correct Answer is B

Explanation

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Explanation

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