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 C
Explanation
A. Prealbumin levels are often used as a marker of nutritional status and can indicate protein deficiency. A low prealbumin level may suggest malnutrition or inadequate protein intake. However, the prealbumin level of 25 mg/dL is within the normal range (normal range typically 15-35 mg/dL), so it does not require immediate reporting to the provider.
B. The client's temperature of 37.6°C (99.7°F) is slightly elevated but is not indicative of a fever (typically defined as ≥38°C or 100.4°F). This finding may suggest a mild increase in body temperature, which could be related to various factors such as dehydration, infection, or environmental factors. Since it's only slightly elevated and within a
borderline range, it may not require immediate reporting unless other concerning symptoms are present.
C. Urine specific gravity measures the concentration of solutes in the urine and can indicate hydration status. A specific gravity of 1.035 is considered high and may suggest concentrated urine, which could be a sign of dehydration or renal dysfunction. Therefore, this finding should be reported to the provider for further evaluation.
D. Hypoactive bowel sounds indicate decreased or absent bowel motility and can be a sign of gastrointestinal dysfunction, such as ileus or obstruction. While it's important to monitor bowel sounds and report any significant changes to the provider, hypoactive bowel sounds alone may not always require immediate reporting unless other concerning symptoms are present.
Correct Answer is D
Explanation
A. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
B. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
C. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
D. To calculate the weight loss percentage, divide the weight lost by the original weight: 6.8/90.7 X 100 = 7.497% = 7.5 % (Rounded off to the nearest tenth)
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