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 C

Explanation

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.

A. Administer enema to relieve constipation. B. Maintain bed rest for 2 days postoperatively. C. Irrigate indwelling urinary catheter with 50 mL of normal saline. D. Place a blanket roll under the client's knees while in bed. E. Apply warm compresses to the incision site

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

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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?

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Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

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