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 B

Explanation

- A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.

- B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.

- C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.

- D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.

A. The nurse places the client on airborne precautions. B. The nurse has the client wear a mask for transport to radiology. C. The nurse wears an N95 respirator when performing client care. D. The nurse ensures the client's room maintains a positive airflow.

Correct Answer is D

Explanation

A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.

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

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