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

Choice A rationale:

Assisted living facilities are suitable for individuals who need assistance with activities of daily living but do not require skilled nursing care. This option might not be necessary based on the partner's exhaustion alone.

Choice B rationale:

Respite care provides temporary relief to caregivers, allowing them to take a break from their caregiving responsibilities. Given the partner's exhaustion, respite care would offer the much-needed rest, reducing caregiver burnout and ensuring better care for the client at home.

Choice C rationale:

Rehabilitation services are designed for patients who need specialized therapy after an illness or injury. While they might be beneficial for the client following a stroke, they do not directly address the partner's exhaustion and need for relief.

Choice D rationale:

Skilled nursing facilities provide 24/7 medical care for individuals with complex medical needs. The partner's exhaustion does not necessarily indicate the need for skilled nursing care, as the client's condition and care requirements were not provided in the scenario.

A. Obtain capillary blood glucose level every 2 hr B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour D. Maintain the affected ankle elevated and immobilized

Correct Answer is C

Explanation

A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.
B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.
C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.
D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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