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.

Check the client's serum albumin levels.

Compare the client's current weight with preprocedure weight.

Examine for leakage at the site of the procedure.

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B.   Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C.   Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D.   Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.

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Correct Answer is D

Explanation

A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited

B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.

C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.

D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.

A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.

Correct Answer is B

Explanation

A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.

B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.

D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.

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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

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