Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Compare the clients current weight with preprocedure weight
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.
B. Examine for leakage at the site of the procedure.
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.
C. Check the client’s serum albumin levels
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.
D. Confirm that the client is able to urinate
wrong because confirming that the client is able to urinate is not related to the paracentesis.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice 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.
Similar Questions
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
A. Use synthetic fabrics for the client’s bedding
because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen. The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.
B. Apply petroleum jelly to soothe the mucous membranes
because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns. The client should use water-based moisturizers to soothe the mucous membranes.
C. Clean the equipment with an alcohol-based cleaning product
because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.
D. Avoid using nail polish remover around the client
Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen. Using nail polish remover around the client can increase the risk of fire and burn injuries.
Full Explanation
The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.
Using nail polish remover around the client can increase the risk of fire and burn injuries.
Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.
The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.
Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.
The client should use water-based moisturizers to soothe the mucous membranes.
Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.
The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.
Some general safety tips for home oxygen therapy are:
- Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
- Do not smoke or allow others to smoke near the oxygen source
- Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
- Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
- Secure oxygen tanks or cylinders to prevent them from falling or rolling
- Use the exact rate of oxygen prescribed by the doctor for each activity
- Check the oxygen gauge or level regularly and call the medical supply company when it is low
- Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
- Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.
Which of the following interventions should the nurse anticipate?
A. Administer a fluid bolus
The client has signs of dehydration and oliguria, which are low urine output and dark yellow urine. A fluid bolus can help restore the fluid balance and improve the renal perfusion. The normal urine output for an adult is 0.5-1.5 mL/kg/hr, and the client’s urine output is only 25 mL/hr, which is below the minimum acceptable level. Dark yellow urine can indicate a high concentration of waste products and a low intake of fluids. Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr.
B. Initiate continuous bladder irrigation
is wrong because continuous bladder irrigation is used to prevent or treat blood clots in the bladder after surgery or injury, not to increase urine output
C. Obtain a urine specimen for culture and sensitivity
wrong because a urine specimen for culture and sensitivity is used to diagnose a urinary tract infection, which is not the most likely cause of the client’s low urine output. The client does not have other symptoms of infection, such as fever, pain, or cloudy urine
D. Clamp the catheter tubing for 30 min
because clamping the catheter tubing for 30 min can cause urinary retention, bladder distension, and increased risk of infection. It can also interfere with the accurate measurement of urine output.
Full Explanation
The correct answer is choice A, administer a fluid bolus.
Choice A rationale:
Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.
Choice B rationale:
Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.
Choice C rationale:
Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.
Choice D rationale:
Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.
A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?
A. Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B. Request a PRN restraint prescription for clients who are aggressive
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C. Attach the restraint to the bed’s side rails
Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D. Remove the client’s restraint every
Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.
Full Explanation
When updating protocols for the use of belt restraints, the nurse manager should include the following guideline:
A) Document the client’s condition every 15 min
Frequent documentation of the client's condition and the need for restraint is essential to monitor their well-being and ensure that restraints are used only when necessary. The other options are not recommended:
B) Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used when there is an immediate risk to the patient or others, and obtaining a PRN prescription for restraints is generally not standard practice.
C) Attaching the restraint to the bed's side rails is not recommended because restraints should be used as a last resort, and there are specific guidelines for restraint application to ensure patient safety.
D) Removing the client's restraint every is not appropriate either. Restraints should only be removed when the client's condition improves, and alternatives to restraint have been explored, or when it's deemed necessary for the patient's safety and well-being following established protocols and guidelines. The option seems incomplete and does not specify the appropriate time frame for removal.