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 A
Explanation
A. Instructing the client to avoid coughing during the procedure is important to prevent disrupting the needle placement during the thoracentesis.
B. The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.
C. Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.
D. The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.
Correct Answer is A
Explanation
A. Frequent swallowing can indicate bleeding post-tonsillectomy, as the child may be swallowing blood from the surgical site.
B. Increased drowsiness is common following surgery, but it is not typically associated with hemorrhage.
C. Elevated pain levels are expected after tonsillectomy and do not necessarily indicate hemorrhage.
D. Diminished breath sounds are not typically associated with hemorrhage but may indicate a respiratory issue.
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