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 ["A","B","D","F","G","I","J"]

Explanation

Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.

Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.

Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.

Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.

Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.

Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.

Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.

A. Ambulate the client every 4 hr while awake. B. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr. C. Provide the client with a 4 g sodium diet. D. Administer enalapril 2.5 mg PO twice daily.

Correct Answer is D

Explanation

A. Although activity is encouraged, clients with acute heart failure may require rest to minimize cardiac demand.
B. Clients with acute heart failure typically need fluid restrictions, not boluses, which could exacerbate heart failure symptoms.
C. A low-sodium diet is usually recommended for heart failure clients to help manage fluid retention, not a high-sodium diet.
D. Enalapril is an ACE inhibitor often prescribed for clients with heart failure as it helps reduce blood pressure and decrease the workload on the heart.

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Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

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

Correct Answer is ["A","B","D","F","G","I","J"]

Explanation

A nurse is admitting a client who has acute heart fallure. Which of the following prescriptions from the provider should the nurse anticipate?

Correct Answer is D

Explanation

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