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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sensation of skin warmth. A warm or flushed sensation is common during cardiac catheterization, especially when contrast dye is injected. This is a normal and temporary response to the dye used in the procedure.
B. Increased salivation. Increased salivation is not a typical reaction during cardiac catheterization. It is not associated with the administration of contrast dye or catheter manipulation.
C. Numbness and tingling of the extremities. Numbness or tingling may indicate compromised circulation or nerve involvement, which is abnormal and should be reported immediately. It may suggest complications like arterial spasm or clot.
D. Headache. Headaches are not expected during a cardiac catheterization. If a headache occurs, especially a severe one, it should be evaluated further, as it could indicate a reaction or another complication.
Correct Answer is D
Explanation
A. The nurse cannot adjust IV antibiotic schedules solely for convenience, as consistent timing is necessary to maintain therapeutic drug levels.
B. Infusing vancomycin at a faster rate is unsafe and increases the risk of complications such as red man syndrome.
C. This is incorrect because the 2-hour administration window applies to non–time-critical medications. IV antibiotics like vancomycin are time-critical and must be given within 30 minutes of the scheduled time.
D. Time-critical medications, such as IV antibiotics, must be administered within 30 minutes before or after the scheduled time, making this the most accurate response.
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