A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?
Place the client in a side-lying position for the procedure.
Administer a low-volume hypertonic enema the night before the procedure.
Weigh the client before and after the procedure.
Ensure the client has a full bladder just prior to the procedure.
The Correct Answer is C
A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
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Related Questions
Correct Answer is C
Explanation
A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.
Correct Answer is B
Explanation
A. Providing a needle exchange program is considered secondary prevention, as it reduces complications in those already using substances rather than preventing initial use.
B. Teaching fifth graders about the risks of substance use is primary prevention, because it aims to stop substance use before it begins.
C. Giving a list of outpatient support services to clients leaving inpatient treatment is tertiary prevention, since it helps prevent relapse in those already affected.
D. Educating pregnant clients who are already in a sober living community is also not primary prevention, because they have a history of substance use; this falls under secondary/tertiary prevention.
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