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 B
Explanation
Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.
While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.
Correct Answer is A
Explanation
Choice A rationale:
Diazepam is a benzodiazepine medication commonly used to manage seizures, including those associated with alcohol withdrawal. It acts as a central nervous system depressant, reducing excessive neuronal activity and helping control seizures. Diazepam is considered the first-line medication for managing alcohol withdrawal seizures due to its efficacy and safety profile when administered under medical supervision.
Choice B rationale:
Naltrexone is an opioid receptor antagonist used primarily to treat alcohol and opioid dependence. It does not have a direct anticonvulsant effect and is not indicated for managing seizures associated with alcohol withdrawal. Naltrexone works by blocking the effects of opioids and reducing cravings, making it valuable in substance use disorder treatment but not in the acute management of seizures.
Choice C rationale:
Acamprosate is another medication used in the treatment of alcohol dependence. It helps maintain abstinence from alcohol by reducing cravings and withdrawal symptoms. However, it does not have anticonvulsant properties and is not used to manage seizures associated with alcohol withdrawal. Acamprosate is more focused on supporting long-term sobriety and preventing relapse in individuals
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