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. While physical therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
B. Occupational therapy may be involved in ALS care for mobility and activities of daily living, they are not the priority for addressing dysphagia.
C. Dysphagia in amyotrophic lateral sclerosis (ALS) requires collaboration with a speech-language pathologist to assess swallowing function, recommend safe
feeding techniques, and possibly provide swallowing therapy. Ensuring adequate nutrition and preventing aspiration are crucial aspects of care for clients with ALS and dysphagia.
D. Consulting a dietitian is important for nutritional support, but ensuring safe swallowing takes precedence.
Correct Answer is B
Explanation
A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.
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