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

A.

Instruct the client to void.

B.

Position the client on their left side.

C.

Insert an IV catheter.

D.

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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Related Questions

Correct Answer is C

Explanation

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

Correct Answer is C

Explanation

How does this make you feel?

  • A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
  • B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
  • C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
  • D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.

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