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 A

Explanation

Choice A rationale

A firm crib mattress is crucial in reducing the risk of Sudden Infant Death Syndrome (SIDS). Soft surfaces can conform to the infant’s face and potentially block their airway, leading to suffocation.

Choice B rationale

Propping the infant with a pillow when in a side-lying position is not recommended as it increases the risk of SIDS. Infants should always be placed on their backs to sleep.

Choice C rationale

Swaddling the infant in a blanket for sleeping is not the most important measure to prevent SIDS. Overheating and loose bedding are risk factors for SIDS23.

Choice D rationale

Placing the infant in a prone position whenever possible is not recommended. Infants should always be placed on their backs to sleep to reduce the risk of SIDS23.

A. Ignore the behavior and proceed with the IV antibiotic administration. B. Instruct the patient to cease the inappropriate behavior. C. Exit the room and close the door quietly. D. Fill out an unusual occurrence report.

Correct Answer is C

Explanation

Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.

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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 is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

Upon entering a patient’s room to administer an IV antibiotic at 0900, the nurse discovers that the patient is engaged in sexual activity with a visitor. What should be the nurse’s course of action?

Correct Answer is C

Explanation

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