A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

Confirm that the client is able to urinate.

Compare the client's current weight with preprocedure weight.

Examine for leakage at the site of the procedure.

Check the client's serum albumin levels.

Answer and Explanation

The Correct Answer is B

A.   While urine output is important, it is not the most direct indicator of the success of a paracentesis.
B.   Comparing the client's weight before and after the procedure helps to evaluate the effectiveness by showing a reduction in fluid buildup.
C.   Leakage at the site could indicate a complication, but it is not the primary measure of the procedure’s
effectiveness.
D.   Serum albumin levels may be monitored but are not the first indicator of success after a paracentesis.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin

Rationale

Administer oxygen at 2 L/min via nasal cannula

The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.

Administer sublingual nitroglycerin

Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.

A. Instruct the client to avoid coughing during the procedure. B. Place the client in the prone position during the procedure. C. Position the client on the affected side for 4 hr following the procedure. D. Inform the client that he will be NPO for 6 hr prior to the procedure.

Correct Answer is A

Explanation

A. Instructing the client to avoid coughing during the procedure is important to prevent disrupting the needle placement during the thoracentesis.
B. The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.
C. Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.
D. The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.

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A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should first dropdownand thendropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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