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.
Check the client's serum albumin levels.
Compare the client's current weight with preprocedure weight.
Examine for leakage at the site of the procedure.
The Correct Answer is C
A. Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B. Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C. Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D. Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. It's important to alternate breasts during feedings to ensure both breasts are stimulated and milk supply is well-maintained.
B. Incorrect. Manually expressing milk can help stimulate milk production and maintain milk supply; it typically does not decrease milk supply.
C. Correct. Frequent and effective breastfeeding, along with proper latching and milk removal, stimulates the production of more milk.
D. Incorrect. Breastfeeding should continue for as long as the baby is actively sucking and swallowing. Babies vary in their feeding patterns, and the length of time at each breast can differ. It's essential to ensure the baby is adequately fed and empties the breast to stimulate milk supply.
Correct Answer is A
Explanation
A. Using an electronic messaging system to remind clients when to take medications is an example of tertiaryprevention, as it aims to prevent the development of complications.
B. Helping clients understand health screenings covered by their insurance plans can be considered primary or secondary prevention, depending on the context.
C. Incorrect. Providing clients with information about the benefits of exercise is an example of health promotion, which is also a component of primary prevention.
D. Educating clients about contraindications to specific immunizations falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.
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