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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.
Choice B: Elevate the head of the bed. Elevating the head of the bed is an important intervention for clients with a small bowel obstruction. It can help reduce abdominal pressure, promote comfort, and facilitate better respiratory function, especially if the client is experiencing any associated nausea or vomiting. This position can also aid in the proper positioning of the intestines, potentially helping with any non-complicated obstructions.
Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the fluid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.
Choice C: Measure abdominal girth daily. While this is an important assessment for monitoring the status of the obstruction, the immediate intervention of elevating the head of the bed can provide immediate comfort and support during the acute phase of the obstruction.
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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