ATI Monroe college NY PN 23NS SP 126 exam 3
ATI Monroe college NY PN 23NS SP 126 exam 3 ( 25 Questions)
A nurse is preparing a client who has advanced cirrhosis for an abdominal paracentesis. Which of the following actions should the nurse take?
Choice A: Place the client on his back. This is incorrect because the client should be placed in a sitting position with the head of the bed elevated to 30 to 45 degrees. This allows the fluid to accumulate in the lower abdomen and reduces the risk of puncturing the diaphragm.
Choice B: Have the client increase fluid intake after the procedure. This is also incorrect because the client should restrict fluid intake after the procedure to prevent fluid overload and electrolyte imbalance. The nurse should monitor the client’s intake and output, weight, and vital signs.
Choice C: Assure the client that the procedure is painless. This is not true because the client may experience some discomfort or pressure during the insertion of the needle or catheter. The nurse should administer analgesics as prescribed and provide emotional support.
Choice D: Instruct the client to empty his bladder. This is correct because this reduces the risk of bladder injury during the procedure. The nurse should also measure and record the amount of urine voided.
Choice A: Place the client on his back. This is incorrect because the client should be placed in a sitting position with the head of the bed elevated to 30 to 45 degrees. This allows the fluid to accumulate in the lower abdomen and reduces the risk of puncturing the diaphragm.
Choice B: Have the client increase fluid intake after the procedure. This is also incorrect because the client should restrict fluid intake after the procedure to prevent fluid overload and electrolyte imbalance. The nurse should monitor the client’s intake and output, weight, and vital signs.
Choice C: Assure the client that the procedure is painless. This is not true because the client may experience some discomfort or pressure during the insertion of the needle or catheter. The nurse should administer analgesics as prescribed and provide emotional support.
Choice D: Instruct the client to empty his bladder. This is correct because this reduces the risk of bladder injury during the procedure. The nurse should also measure and record the amount of urine voided.