A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

Every 1 hour for 2 hours.

Every 5 minutes for one hour.

Every 15 minutes for one hour, then every 1 hour for 2 hours.

Every 5 minutes for 30 minutes, then every 4 hours thereafter.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Monitoring the patient’s blood pressure every 1 hour for 2 hours after paracentesis may not be sufficient. Paracentesis is a procedure to remove fluid that has accumulated in the abdominal cavity (a condition called ascites). This is a common problem in people with certain diseases, including liver and kidney disease. Changes in blood pressure can occur rapidly after this procedure, so more frequent monitoring is needed immediately after the procedure.
Choice B rationale
Monitoring the patient’s blood pressure every 5 minutes for one hour after paracentesis may be too frequent and could cause unnecessary stress for the patient. It is important to balance the need for monitoring with the patient’s comfort and well-being.
Choice C rationale
Monitoring the patient’s blood pressure every 15 minutes for one hour, then every 1 hour for 2 hours after paracentesis is a good schedule. This allows for close monitoring immediately after the procedure, when complications are most likely to occur. It then allows for continued monitoring as the patient stabilizes.
Choice D rationale
Monitoring the patient’s blood pressure every 5 minutes for 30 minutes, then every 4 hours thereafter may not provide enough monitoring in the immediate post-procedure period. While it is important to continue monitoring, the first few hours after the procedure are a critical time when complications are most likely to occur.

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Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it may not be appropriate for all patients, especially those with certain medical conditions or those who are NPO (nothing by mouth)7.
Choice B rationale

Feeding the client a snack can help maintain energy levels, but it may not be appropriate for all patients, especially those with dietary restrictions or those who are NPO7.
Choice C rationale
Assessing breath sounds is an important part of respiratory assessment, but it is not typically within the scope of practice for unlicensed assistive personnel (UAP). This task should be performed by a licensed nurse.
Choice D rationale
Emptying the urinary drainage bag is an appropriate task for a UAP to perform each time the client is turned. This helps ensure accurate measurement of urinary output and prevents infection by keeping the bag below the level of the bladder.

A. Administer oxygen via a face mask. B. Apply an internal fetal heart monitor. C. Use a vibroacoustic stimulator. D. Notify the healthcare provider.

Correct Answer is A

Explanation

Choice A rationale
Administering oxygen via a face mask is the first intervention the nurse should do. This is because the decrease in fetal heart rate after the last four contractions indicates possible fetal distress, which can be caused by insufficient oxygen. Administering oxygen to the mother can increase the amount of oxygen available to the fetus, potentially alleviating the distress.
Choice B rationale
Applying an internal fetal heart monitor can provide more accurate and continuous data about the fetal heart rate and contractions. However, this is usually not the first intervention because it is invasive and can only be done if the cervix is sufficiently dilated and the membranes have ruptured.
Choice C rationale
Using a vibroacoustic stimulator is a method used to wake a sleeping baby in the womb during a non-stress test. It is not typically used in response to signs of fetal distress during labor.

Choice D rationale
Notifying the healthcare provider is important when there are signs of fetal distress. However, the nurse has interventions, such as administering oxygen, that they can and should do immediately while the healthcare provider is being notified.

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A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to perform each time the client is turned?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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