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
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
Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood. A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume.
The normal range for Hct is 38% to 50% for males and 36% to 44% for females.
Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.
A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.
Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.
A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.
Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.
A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.
Correct Answer is B
Explanation
The correct answer is b. “I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
Choice A rationale:
- Statement:“I should take antibiotics when I have a virus.”
- Rationale:This statement is incorrect.Antibiotics are medications that fight bacteria,not viruses.Taking antibiotics when you have a virus will not help you get better and can actually lead to antibiotic resistance.
Choice B rationale:
- Statement:“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
- Rationale:This statement is correct.Chickenpox is a highly contagious virus that is spread through the air by coughing and sneezing.However,a person with chickenpox is no longer contagious once all of the sores have crusted over.This typically happens about 5 days after the rash first appears.
Choice C rationale:
- Statement:“I should wash my hands for 10 seconds with hot water after working in the garden.”
- Rationale:This statement is partially correct.Handwashing is an important way to prevent the spread of infection.However,the water does not need to be hot.Warm or cold water is just as effective.It is also important to wash your hands for at least 20 seconds,not 10 seconds.
Choice D rationale:
- Statement:“I can clean my cat’s litter box during my pregnancy.”
- Rationale:This statement is incorrect.Cat feces can contain a parasite called Toxoplasma gondii,which can cause a serious infection called toxoplasmosis.Toxoplasmosis can be harmful to a developing baby.It is best to avoid cleaning cat litter boxes during pregnancy.If you must clean the litter box,wear gloves and wash your hands thoroughly afterwards.
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