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?

Compare the clients current weight with preprocedure weight

Examine for leakage at the site of the procedure.

Check the client’s serum albumin levels

Confirm that the client is able to urinate

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.

Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.

Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.

Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.

Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.

Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.

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Correct Answer is C

Explanation

The correct answer is choice C. Perform the procedure prior to meals.

This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.

If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.

Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.

Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.

Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.

Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.

A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.

A. “Have you taken your medication today?”. B. “How long have you been hearing the voices?”. C. “What are the voices telling you?”. D. “I realize the voices are real to you, but I don’t hear anything.”. E. undefined

Correct Answer is C

Explanation

The correct answer is choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.

The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).

The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).

The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).

The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Explanation

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