A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?
Every 5 minutes for 30 minutes, then every 4 hours thereafter.
Every 5 minutes for one hour.
Every 15 minutes for one hour, then every 1 hour for 2 hours.
Every 1 hour for 2 hours.
The Correct Answer is C
A. Monitoring every 5 minutes for 30 minutes then every 4 hours is not sufficiently structured for ongoing early detection of delayed hypotension after significant fluid removal.
B. Monitoring every 5 minutes for one hour may be unnecessarily frequent for a stable post-paracentesis client and does not provide appropriate step-down surveillance beyond the first hour.
C. Monitoring every 15 minutes for one hour allows close observation during the highest-risk period immediately after the procedure, followed by every 1 hour for 2 hours to continue surveillance as the client stabilizes. This schedule aligns with standard post-paracentesis monitoring for potential hypotension and fluid shifts.
D. Monitoring every 1 hour for 2 hours alone is insufficient in the immediate post-procedure phase, as it does not provide close enough observation during the highest risk period.
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Related Questions
Correct Answer is D
Explanation
A. Provide high protein snacks. High protein snacks may exacerbate the symptoms of CKD by increasing urea and creatinine levels further. It is not recommended.
B. Administer PRN oxygen. Oxygen therapy is not indicated based on the symptoms described and the laboratory findings of elevated BUN and serum creatinine.
C. Monitor glucose levels every 4 hours. Monitoring glucose levels is not directly related to the symptoms described or the laboratory findings associated with CKD.
D. Schedule frequent rest periods. Fatigue and difficulty concentrating are common symptoms of CKD due to the buildup of waste products in the blood. Scheduling frequent rest periods can
help alleviate these symptoms and improve the client's overall well-being.
Correct Answer is C
Explanation
A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.
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