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.
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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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Refuting delusions using logic can increase agitation and confusion. Instead, the nurse should offer reassurance and validation without arguing.
B. Giving the client one simple direction at a time helps minimize confusion and enhances the client’s
ability to follow instructions.
C. Establishing eye contact is important for communication and shows attentiveness, helping the client feel connected.
D. Allowing the client to choose among activities provides a sense of autonomy and can reduce agitation.
E. Reinforcing orientation helps maintain the client’s awareness of time, place, and person, which can reduce disorientation and anxiety.
Correct Answer is D
Explanation
A. Negligence involves a failure to provide reasonable care, but it does not apply here since the AP’s
actions were intentional.
B. Battery is the intentional and harmful physical contact with another person without their consent. In the context of healthcare, this could involve actions like physically restraining a patient without consent, administering medication without consent, or any physical contact that is deemed offensive and unwarranted.
C. Malpractice refers to professional negligence by a healthcare provider, which is not the case here.
D. Assault occurs when there is an intentional act that creates a fear of imminent harmful or offensive contact with another person, even if no actual physical contact occurs. In this case, the AP's statement, "If you don't eat, I'll put restraints on your wrists and feed you," is a verbal threat of harm.
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