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.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
A. Alcohol-based products should be avoided because they can be flammable when used near oxygen.
B. Petroleum jelly should not be used with oxygen therapy, as it is flammable. Water-based products are a safer option.
C. Nail polish remover, like other flammable liquids, should be avoided when using oxygen due to fire hazards.
D. Synthetic fabrics can generate static electricity, which may pose a risk near oxygen sources. Cotton fabrics are safer.
Correct Answer is A
Explanation
A. Suctioning should be applied for no more than 10-15 seconds to prevent hypoxia. Prolonged suctioning can cause airway trauma and a decrease in oxygen saturation.
B. Encouraging the client to cough helps to clear the airway and is a positive action.
C. Waiting for 2 minutes between suctions is appropriate to allow for reoxygenation of the client.
D. Inserting the catheter without applying suction is the correct technique, as suction should only be applied when the catheter is withdrawn.
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