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 A

Explanation

A. Correct. Evaluating the client's ability to assist with repositioning is important to ensure safe and appropriate positioning that considers the client's capabilities and comfort.
B. Incorrect. The use of assistive devices or assistance from the nurse or other personnel may be necessary to ensure safe repositioning, especially in clients with mobility limitations.
C. Incorrect. While discussing the client's preferences is important, it may not directly relate to the immediate need for repositioning after a stroke.
D. Incorrect. Raising the side rails on both sides of the bed is important for client's safety, but it doesn't address the client's need for repositioning after a stroke.

A. Bulging fontanels B. Hypertonicity C. Bradycardia D. Acrocyanosis

Correct Answer is B

Explanation

A. Incorrect. Bulging fontanels are not typically associated with withdrawal from maternal methadone use. They might indicate increased intracranial pressure or other conditions.
B. Correct. Hypertonicity, or increased muscle tone, is a common sign of neonatal withdrawal from opioids such as methadone. It can manifest as increased resistance to passive movement.
C. Incorrect. Bradycardia is not a common withdrawal symptom from maternal methadone use. Neonates withdrawing from opioids might experience tachycardia, not bradycardia.
D. Incorrect. Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to withdrawal from methadone. It can be related to immature peripheral circulation.

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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

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

Correct Answer is B

Explanation

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