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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.
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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