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","C","E"]
Explanation
The nurse should include the following statements in the teaching:
- You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
- Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
- You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.
Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.
Correct Answer is ["C","E"]
Explanation
Preterm pre-labor rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac before the onset of labor in a pregnancy less than 37 weeks gestation. It can lead to
infection, cord prolapse, placental abruption, and preterm delivery. The client has risk factors for PROM such as a history of preterm birth and a current infection indicated by fever.
Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. The client has signs of sepsis such as fever, tachycardia, and possible organ dysfunction. The client may have a urinary tract infection, a common cause of sepsis in pregnancy, or an intrauterine infection due to PROM or other factors.
Preeclampsia is not a likely complication for this client because she does not have high blood pressure or proteinuria, which are the defining features of preeclampsia. Seizures are not a likely complication for this client because she does not have epilepsy or eclampsia, which are the leading causes of seizures in pregnancy. Placenta previa is not a likely complication for this client because she does not have painless vaginal bleeding, which is the hallmark symptom of placenta previa.
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