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 C

Explanation

Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.

Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.

Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.

Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.

A. Tachycardia B. Blurry vision C. Sweating D. Polydipsia E. Polyuria

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.

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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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