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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.
Correct Answer is A
Explanation
The correct answer is choicea. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia.The fetus relies on maternal glucose for energy, and a significant drop in maternal glucose levels can affect the fetal heart rate.
Choice B rationale:
Maternal fever is typically associated with fetal tachycardia rather than bradycardia.An elevated maternal temperature can increase the fetal heart rate as the fetus attempts to regulate its own temperature.
Choice C rationale:
Chorioamnionitis, an infection of the amniotic fluid and membranes, is also more commonly associated with fetal tachycardia due to the inflammatory response and fever.
Choice D rationale:
Fetal anemia can cause fetal tachycardia as the fetus compensates for the reduced oxygen-carrying capacity of the blood.Bradycardia is not a typical response to fetal anemia.
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