A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?
Position the client over an overbed table prior to the procedure.
Instruct the client to empty her bladder prior to the procedure.
Administer 1 L dextrose 5% in water IV bolus prior to the procedure.
Initiate NPO status 4 hr prior to the procedure.
The Correct Answer is B
A. Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B. Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C. Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D. NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.
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Related Questions
Correct Answer is B
Explanation
A. This amount of residual is generally considered safe; guidelines often cite higher residuals (e.g., >100 mL) as concerning.
B. Clients with a history of gastroesophageal reflux disease (GERD) are at increased risk for aspiration, particularly when lying flat, because the lower esophageal sphincter may not function properly, allowing stomach contents to move back into the esophagus.
C. While high-osmolarity formulas can contribute to diarrhea, they are not directly linked to an increased risk of aspiration.
D. Sitting in a high-Fowler’s position (semi-upright) during feedings is actually recommended to reduce the risk of aspiration.
Correct Answer is D
Explanation
A. Potatoes do not contain significant levels of tyramine and are generally safe to consume with MAOIs.
B. Grapefruit does not contain significant levels of tyramine and are generally safe to consume with MAOIs.
C. Eggs do not contain significant levels of tyramine and are generally safe to consume with MAOIs.
D. MAOIs (Monoamine Oxidase Inhibitors) require dietary restrictions to avoid tyramine, which is found in high levels in aged cheeses. High tyramine intake while on MAOIs can lead to hypertensive crises.
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