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.
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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Related Questions
Correct Answer is B
Explanation
A. Informing the client that their name cannot be removed once listed may deter individuals from considering organ donation. In reality, individuals can update or revoke their consent at any time.
B. Organ donation requires documented consent, either through advance directives or donor registry enrollment. Verbal consent alone is not sufficient. The nurse should educate the client about the importance of documenting their wishes regarding organ donation.
C. Declaring that the nurse cannot be a witness for consent is inaccurate. Witnesses may be required depending on local regulations, but healthcare professionals can serve as witnesses.
D. Specifying a minimum age requirement for organ donation is incorrect. Organ donation eligibility depends on various factors beyond age, such as overall health and the condition of organs at the time of death.
Correct Answer is A
Explanation
A. Basal body temperature should be measured immediately upon waking and before any physical activity to ensure accuracy in detecting the slight temperature rise after ovulation.
B. Temperature taken after getting out of bed may not accurately reflect the basal body temperature.
C. Basal body temperature is best measured in the morning.
D. The timing here still allows for too much activity before measuring temperature, which can affect the reading.
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