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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice a. Maternal hypoglycemia.
Choice A rationale:
Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function.
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Choice B rationale:
Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one.
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Choice C rationale:
Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.
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Choice D rationale:
Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.
Correct Answer is B
Explanation
The correct answer is choiceb. Waits for 2 min between suctions.
Choice A rationale:
Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.
Choice B rationale:
Waiting for 2 minutes between suctions is too long.The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.
Choice C rationale:
Applying suction for 15 seconds is within the recommended duration.Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.
Choice D rationale:
Encouraging the client to cough during suctioning is appropriate.Coughing helps to mobilize secretions and can make suctioning more effective.
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