A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void.

Position the client on their left side.

Insert an IV catheter.

Prepare the client for moderate (conscious) sedation.

Answer and Explanation

The Correct Answer is A

Option A. Instruct the client to void, because this reduces the risk of bladder injury during the procedure. The other options are incorrect because they are not necessary or appropriate for a paracentesis.

Option B, position the client on their left side, is incorrect because the client should be positioned upright or semi-Fowler's to allow gravity to assist with fluid drainage.

Option C, insert an IV catheter, is incorrect because an IV catheter is not required for a paracentesis unless the client needs fluid replacement or medication administration.

Option D, prepare the client for moderate (conscious) sedation, is incorrect because a paracentesis is usually performed under local anesthesia and does not require sedation.

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Correct Answer is C

Explanation

A. The frequency in which the client presses the call button is not a priority for the change-of-shift report, as it does not indicate the level of pain or comfort of the client. This choice is incorrect.

B. The client's most recent ventilator settings are not applicable, as the client was weaned from mechanical ventilation and no longer requires it. This choice is incorrect.

C. The time of the client's last dose of pain medication is important for the change-of-shift report, as it helps to ensure continuity of care and prevent under- or over-medication of the client. This choice is correct.

D. The last time the provider evaluated the client is not relevant for the change-of-shift report, as it does not reflect the current status of the client. This choice is incorrect.

A. Increased food intake B. Can perform ADLS independently C. Improved short-term memory D. Enhanced mood

Correct Answer is C

Explanation

Choice A reason

Increased food intake does not show medication is effective: Increased food intake is not a specific indication of donepezil's effectiveness. While some clients with dementia may have improved appetite due to reduced agitation or confusion, it is not directly related to the medication's therapeutic effect.

Choice B reason:

Can perform ADLs independently is inappropriate: The ability to perform activities of daily living (ADLs) independently can be a positive outcome in clients with dementia. However, it may not be solely attributed to donepezil, as ADLs can be influenced by various factors, including the client's overall condition and support received.

Choice C reason:

Improved short-term memory is correct. One of the primary goals of using donepezil is to improve memory and slow the decline in cognitive abilities associated with dementia. Therefore, if a client shows improvement in short-term memory, it suggests that the medication is having a positive effect in preserving cognitive function.

Choice D reason

Enhanced mood does not show the medicine is effective: Donepezil is primarily aimed at improving cognitive function and memory, and its effects on mood may be limited. While some clients may experience mood improvements due to reduced frustration or confusion from memory loss, it is not the primary indicator of the medication's effectiveness.

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A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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