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
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Correct Answer is ["A","B","C","E"]
Explanation
Client reports lower back pain and pinkish vaginal discharge.
- Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
- Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.
FHR baseline 145, minimal variability.
- Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.
Cervical exam indicates 2 cm, 50% effaced, 0 station.
- Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.
Correct Answer is A
Explanation
A. Correct. Furosemide is a diuretic that promotes the excretion of excess fluid and electrolytes. Weight loss is a direct outcome of diuresis and indicates the effectiveness of furosemide in reducing fluid volume excess.
B. Increased blood pressure is not an expected outcome of furosemide administration.
Furosemide is commonly used to reduce blood pressure in clients with fluid volume excess.
C. Decreased pain and decreased inflammation are not direct outcomes of furosemide administration.
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