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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. While the nurse is curious about the client's reasons, it may come across as intrusive or defensive.
B. Incorrect. Making an assumption about the client's potential benefit is not appropriate. The client has the right to access their own records.
C. Correct. This response is respectful of the client's request while also explaining the limitation related to therapist notes.
D. Incorrect. The about the client's happiness with treatment is not directly related to their request for therapist notes.
Correct Answer is C
Explanation
A. Incorrect. Acting seductively is more characteristic of histrionic personality disorder.
B. Incorrect. Being overly concerned about minor details is more characteristic of obsessive-compulsive personality disorder.
C. Correct. Impulsive behavior, such as reckless spending or self-harm, is a common feature of borderline personality disorder.
D. Incorrect. Being exceptionally clingy to others is not a defining feature of borderline personality disorder.
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