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

Answer and Explanation

The Correct Answer is A

The correct answer is choice 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.

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Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.

Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.

Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.

Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.

A. Determine previous coping skills used by the client. B. Facilitate the client's problem-solving skillls C. Assist the client in expressing alternative behaviours. D. Establish the responsibilities of the nurse and client

Correct Answer is D

Explanation

Choice A reason:

Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.

Choice B reason:

Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.

Choice Creason:

Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.

Choice D reason:

The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

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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

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Explanation

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