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 ["A","D","E","F","G"]
Explanation
Based on the information provided, the nurse should consider the following client findings for further evaluation:
A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.
D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.
E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.
F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.
G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.
The following client findings do not necessarily indicate the need for further evaluation in this context:
B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.
C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.
A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.
Correct Answer is ["C","D","G"]
Explanation
Choice A reason:
"Try using an abdominal support belt". This statement is incorrect. There is no indication or relevance for using an abdominal support belt based on the vital signs and weight provided. This statement is not appropriate for the client's teaching.
Choice B reason:
"Take hot showers to help relieve itching" This statement is incorrect. Itching is not mentioned in the vital signs and weight provided. Additionally, taking hot showers might not be relevant to the client's condition or needs. This statement is not appropriate for the client's teaching.
Choice C reason:
"Wear loose-fitting clothing" This is an appropriate statement for the client's teaching. Wearing loose-fitting clothing can provide comfort and allow better circulation, which might be helpful for some clients.
Choice D reason:
"Wear flat or low-heeled shoes" This is an appropriate statement for the client's teaching. Wearing flat or low-heeled shoes can help provide comfort and support, especially if the client has any foot or back issues.
Choice E reason:
"You can douche twice weekly." Douche is not relevant to the vital signs and weight provided, and it is generally not recommended for routine use as it can disrupt the natural balance of vaginal flora. This statement is not appropriate for the client's teaching.
Choice F reason:
"Eat two large meals a day." This statement does not align with a healthy eating pattern, and it might not be appropriate for the client's health needs. The recommendation for a balanced diet usually includes several smaller meals throughout the day. This statement is not appropriate for the client's teaching.
Choice G reason:
"You should avoid fried foods." This is an appropriate statement for the client's teaching. Avoiding fried foods can be beneficial for overall health, especially if the client is trying to manage weight or maintain a balanced diet.
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