A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

Position the client over an overbed table prior to the procedure.

Instruct the client to empty her bladder prior to the procedure.

Administer 1 L dextrose 5% in water IV bolus prior to the procedure.

Initiate NPO status 4 hr prior to the procedure.

Answer and Explanation

The Correct Answer is B

A.   Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B.   Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C.   Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D.   NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.

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Correct Answer is B

Explanation

A: Placing the bedside table at the foot of the bed may not directly reduce the risk of injury for a client with dementia.
B: Assisting the client to the toilet frequently can prevent falls and accidents associated with incontinence, which are common concerns for clients with dementia.
C: Raising the side rails up can potentially increase the risk of injury if the client attempts to climb over them, leading to falls or entrapment.
D: Keeping the television on during the night may not directly address the risk of injury for the client.

A. Add medication directly to enteral feeding. B. Flush the NG tube with 5 mL water. C. Dissolve the medications together. D. Use a syringe to allow the medications to flow by gravity.

Correct Answer is D

Explanation

A. Adding medication directly to enteral feeding can cause clogging of the tube and interfere with medication absorption.
B. Flushing with only 5 mL of water is insufficient. Typically, the tube should be flushed with 15-30 mL of water before and after administering each medication to ensure the tube is clear and to prevent clogging.
C. Dissolving medications together may lead to drug interactions or alterations in drug absorption and should be avoided.
D. Using a syringe to allow the medications to flow by gravity ensures that the medications are delivered safely and steadily. After each medication is administered, the tube should be flushed with water to ensure it is clear and to prevent interactions between different medications.

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A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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