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 C

Explanation

A. Circulatory overload is characterized by symptoms such as dyspnea, crackles, and increased blood pressure, rather than localized redness and warmth.
B. Extravasation refers to the leakage of IV fluid into surrounding tissue, causing swelling and pain.
C. Redness and warmth around the peripheral catheter insertion site are indicative of phlebitis, which is inflammation of the vein. It's essential to document this finding accurately to monitor for worsening or complications.
D. Infiltration occurs when IV fluid leaks into the surrounding tissue, but it typically presents with swelling, pallor, and coolness at the site rather than redness and warmth.

A. Reevaluate the client for an ET cuff leak. B. Assess for disconnected tubing. C. Deliver breaths manually with a resuscitation bag. D. Decrease the ventilator flow rate.

Correct Answer is C

Explanation

A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.

B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.

C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.

D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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