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 D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the appropriate method for administering the medication. This would dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the appropriate method for administering the medication. This would significantly dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice C rationale
Requesting the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the appropriate method for administering the medication. While dextrose is often a component of TPN solutions, in this case, the patient requires a concentrated dose of dextrose to treat insulin shock.
Choice D rationale
This is the correct answer. Administering the undiluted dextrose slowly through the currently infusing IV is the appropriate method for administering the medication. This allows for the rapid administration of a concentrated dose of glucose, which is necessary to quickly raise the patient’s blood glucose level in the case of insulin shock.
Correct Answer is D
Explanation
Choice A rationale
While any positive response on the CAGE questionnaire could be a cause for concern and warrant further investigation, one positive response does not definitively indicate that the patient should seek help with alcohol addiction. The CAGE questionnaire is a screening tool used to identify potential problems with alcohol, but it is not diagnostic. A healthcare provider would need to conduct a more thorough assessment to diagnose alcohol addiction.
Choice B rationale
It is not necessary for all responses to the CAGE questionnaire to be positive in order to suggest alcohol dependence. The CAGE questionnaire is a screening tool, and while a greater number of positive responses increases the likelihood of alcohol dependence, it is not a requirement for all responses to be positive. A score of two or more is considered clinically significant.
Choice C rationale
The CAGE questionnaire is indeed a tool used to identify potential problems with alcohol, but it is not used to identify general substance abuse. The CAGE questionnaire specifically asks about feelings related to alcohol use. There are other screening tools available that are designed to identify issues with other substances.
Choice D rationale
This is the correct answer. The CAGE questionnaire is a validated screening tool that is widely used in clinical settings to detect alcoholism. It is considered positive, and suggestive of alcohol dependence, if two or more questions are answered affirmatively.
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