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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fidelity refers to the principle of being loyal, faithful, and keeping promises. It does not specifically relate to providing accurate information about treatment effects. In this scenario, the nurse is discussing the potential adverse effects of a treatment, which falls under the domain of providing accurate and truthful information to the client.
Choice B rationale:
Beneficence is the ethical principle of doing good and promoting the well-being of the patient. While educating the client about potential adverse effects is a form of beneficence, the specific principle demonstrated in this scenario is veracity, which is the duty to tell the truth. The nurse is being truthful about the potential side effect (lightheadedness) while clarifying that it should not affect memory.
Choice C rationale:
Veracity is the ethical principle of truth-telling. In this scenario, the nurse is demonstrating veracity by providing honest and accurate information to the client about the potential adverse effects of transcranial magnetic stimulation. By being truthful, the nurse upholds the ethical principle of veracity.
Choice D rationale:
Autonomy refers to the principle of respecting the patient's right to make decisions about their own healthcare. While respecting autonomy is important, the nurse's action in this scenario specifically pertains to providing accurate information (veracity) rather than solely focusing on the client's decision-making autonomy.
Correct Answer is A
Explanation
Choice A rationale:
A blood lead level of 18 mcg/dL in a 9-month-old infant is elevated. The Centers for Disease Control and Prevention (CDC) considers a blood lead level of 5 mcg/dL or higher in children to be concerning. Lead exposure can lead to developmental delays and cognitive impairments. Therefore, this result needs to be reported to the healthcare provider promptly.
Choice B rationale:
Hemoglobin level of 12 g/dL is within the normal range for a 9-month-old infant (11-15 g/dL) There is no need to report this result to the provider.
Choice C rationale:
Iron level of 74 mcg/dL is within the normal range for a 9-month-old infant (50-120 mcg/dL) There is no need to report this result to the provider.
Choice D rationale:
Hematocrit level of 35% is within the normal range for a 9-month-old infant (29-41%) There is no need to report this result to the provider.
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