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?

Compare the clients current weight with preprocedure weight.

Examine for leakage at the site of the procedure.

Check the client’s serum albumin levels.

Confirm that the client is able to urinate.

Answer and Explanation

The Correct Answer is A

Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.

Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.

Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.

Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.

Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.

Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.

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Correct Answer is D

Explanation

This prescription is complete because it includes the medication name, dose, route, and frequency. A complete prescription should also include the client’s name, date, time, signature of the prescriber, and any special instructions.

Choice A is wrong because it does not specify the dose of cimetidine.

PO twice daily is not enough information to administer the medication safely. Choice B is wrong because it does not specify the frequency of tetracycline.

200 mg PO is not enough information to administer the medication safely. Choice C is wrong because it does not specify the route of epoetin alfa.

150 units/kg three times weekly is not enough information to administer the medication safely.

Normal ranges for digoxin are 0.5 to 2 ng/mL for heart failure and 0.8 to 2 ng/mL for atrial fibrillation.

Normal ranges for cimetidine are 50 to 150 ng/mL. Normal ranges for tetracycline are 1 to 10 mcg/mL.

Normal ranges for epoetin alfa are not applicable as it is a synthetic hormone that stimulates red blood cell production.

A. A client who received a Mantoux test 48 hr ago and has an induration. B. A client who is scheduled for a colonoscopy and is taking sodium phosphate. C. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L. D. A client who is taking warfarin and has an INR of 1.8.

Correct Answer is D

Explanation

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.

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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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