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 D

Explanation

A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

A. Using an electronic messaging system to remind clients when to take medications B. Helping clients understand health screenings covered by their insurance plans C. Providing clients with information about the benefits of exercise D. Educating clients about contraindications to specific immunizations

Correct Answer is A

Explanation

A. Using an electronic messaging system to remind clients when to take medications is an example of tertiaryprevention, as it aims to prevent the development of complications.
B. Helping clients understand health screenings covered by their insurance plans can be considered primary or secondary prevention, depending on the context.
C. Incorrect. Providing clients with information about the benefits of exercise is an example of health promotion, which is also a component of primary prevention.
D. Educating clients about contraindications to specific immunizations falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.

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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

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