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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Replacing the IV site with a smaller gauge is not the most appropriate intervention in this situation. The client’s confusion and picking at the dressing and tape are likely due to the dementia and increased confusion at night, known as “sundowning”. While a smaller gauge might be less noticeable to the client, it does not address the primary issue of the client’s confusion and restlessness at night.
Choice B rationale
Applying soft bilateral wrist restraints might be considered in some situations to prevent a confused client from removing necessary medical devices. However, restraints should be a last resort after all other interventions have been tried because they can increase agitation and confusion, and they pose a risk for injury.
Choice C rationale
Redressing the abdominal incision is the correct choice. The dressing is no longer occlusive, which means it’s not providing a proper barrier to bacteria. This could lead to an infection in the surgical site. The nurse should clean the area and apply a new sterile dressing.
Additionally, the nurse should continue to monitor the client’s behavior and implement interventions to reduce confusion and restlessness, such as reorienting the client and providing a quiet and calm environment.
Choice D rationale
Leaving the lights on in the room at night can actually increase confusion and agitation in clients with dementia. It can disrupt the client’s sleep-wake cycle and make “sundowning” worse. Therefore, this is not the most appropriate intervention.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale
A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.
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