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.

Answer and Explanation

The Correct Answer is A

A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.

B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and

may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring

initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

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Correct Answer is C

Explanation

A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect

catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.

D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.

A. Core strengthening. B. Aerobic exercise. C. Weight-bearing exercise. D. Muscle stretching and toning.

Correct Answer is C

Explanation

A. Core strengthening. While important for overall health, core strengthening is not as directly effective for osteoporosis prevention as weight-bearing exercise.
B. Aerobic exercise. Aerobic exercise is beneficial for cardiovascular health but does not have the same bone-strengthening effect as weight-bearing exercise.
C. Weight-bearing exercise. Weight-bearing exercises, such as walking, jogging, and strength training, are essential for maintaining bone density and preventing osteoporosis.
D. Muscle stretching and toning. Stretching and toning are important for flexibility and muscle health but do not significantly impact bone density compared to weight-bearing exercises.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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