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 D

Explanation

Choice Arationale:

Allowing the client to eat meals in his room might not be the best approach. Patients with anorexia nervosa often have distorted body image and may engage in secretive behaviors related to food intake. Supervised meals and observation during and after meals are essential to prevent behaviors like purging.

Choice B rationale:

Weighing the client every 48 hours is not frequent enough for a patient with anorexia nervosa. Daily weight monitoring is crucial in these cases because rapid weight loss or fluctuations can indicate worsening malnutrition, dehydration, or other medical complications.

Choice Crationale:

Obtaining vital signs every other day might not provide an accurate picture of the client's overall health status, especially during the critical early phase of care. In anorexia nervosa, patients are at risk of severe complications such as electrolyte imbalances, cardiac issues, and malnutrition, which can rapidly change and require close monitoring.

Choice D rationale:

Observing the client for 1 hour after meals is a crucial nursing intervention for individuals with anorexia nervosa. After meals, these patients are at risk of engaging in purging behaviors like vomiting or excessive exercise to compensate for caloric intake. Close observation can help prevent these behaviors and ensure the client's safety.

A. "I'll use isopropyl alcohol to clean my hearing aids.” B. "I'll replace the batteries every 2 weeks.” C. "I'll clean my ear with cotton swabs before I insert my hearing aids.” D. "I'll disconnect the battery when I remove my hearing aids.”

Correct Answer is D

Explanation

Choice A rationale:

Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.

Choice B rationale:

Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.

Choice C rationale:

Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.

Choice D rationale:

Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.

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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

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching a client how to care for his behind-the-ear hearing aids.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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