A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the following actions should the nurse take?

Place the client on his back.

Have the client increase ﬂuid intake after the procedure.

Assure the client that the procedure is painless.

Instruct the client to empty his bladder.

Answer and Explanation

The Correct Answer is D

Choice A: Place the client on his back. This is incorrect because the client should be placed in a sitting position with the head of the bed elevated to 30 to 45 degrees. This allows the ﬂuid to accumulate in the lower abdomen and reduces the risk of puncturing the diaphragm.

Choice B: Have the client increase ﬂuid intake after the procedure. This is also incorrect because the client should restrict ﬂuid intake after the procedure to prevent ﬂuid overload and electrolyte imbalance. The nurse should monitor the client’s intake and output, weight, and vital signs.

Choice C: Assure the client that the procedure is painless. This is not true because the client may experience some discomfort or pressure during the insertion of the needle or catheter. The nurse should administer analgesics as prescribed and provide emotional support.

Choice D: Instruct the client to empty his bladder. This is correct because this reduces the risk of bladder injury during the procedure. The nurse should also measure and record the amount of urine voided.

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Correct Answer is ["A","B","C"]

Explanation

Choice A reason: Tachycardia is a common symptom of hypoglycemia, as the body releases adrenaline and other hormones to raise the blood sugar level. This can cause the heart to beat faster and stronger.

Choice B reason: Blurry vision is a common symptom of hypoglycemia, as low blood sugar can aﬀect the ability of the eyes to focus and see clearly. This can also cause headaches, dizziness, or double vision.

Choice C reason: Sweating is a common symptom of hypoglycemia, as the body tries to cool down and cope with the stress of low blood sugar. This can also cause shakiness, trembling, or tingling in the lips, tongue, or cheek.

Choice D reason: Polydipsia (excessive thirst) is not a symptom of hypoglycemia, but a symptom of hyperglycemia (high blood sugar). High blood sugar can cause dehydration and dry mouth, which make the person feel thirsty.

Choice E reason: Polyuria (excessive urination) is not a symptom of hypoglycemia, but a symptom of hyperglycemia (high blood sugar). High blood sugar can cause the kidneys to filter out excess glucose and water from the blood, which make the person urinate more often.

A. Thyroxine (T4) level B. Triiodothyronine (T3) level C. Thyroid stimulating hormone (TSH) level D. Glucose level

Correct Answer is C

Explanation

Choice A: Thyroxine (T4) level. This is incorrect because T4 is one of the thyroid hormones that is increased in hyperthyroidism. T4 is produced by the thyroid gland and converted to T3 in the tissues. A high level of T4 indicates overactivity of the thyroid gland.1

Choice B: Triiodothyronine (T3) level. This is incorrect because T3 is another thyroid hormone that is increased in hyperthyroidism. T3 is the more active form of thyroid hormone and regulates the metabolism of cells. A high level of T3 indicates overactivity of the thyroid gland.1

Choice C: Thyroid stimulating hormone (TSH) level. This is correct because TSH is a hormone that stimulates the thyroid gland to produce T4 and T3. TSH is produced by the pituitary gland and regulated by a feedback mechanism. When the levels of T4 and T3 are high, the pituitary gland reduces the secretion of TSH to inhibit further production of thyroid hormones. Therefore, a low level of TSH indicates hyperthyroidism.1

Choice D: Glucose level. This is incorrect because glucose level is not directly related to thyroid function. However, hyperthyroidism can aﬀect glucose metabolism and cause increased blood sugar levels due to increased breakdown of glycogen and glucose uptake by cells. Therefore, glucose level may be elevated in some cases of hyperthyroidism, but it is not a specific indicator.

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A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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