32. A client with ascites as a result of hepatitis C is in the emergency department complaining of abdominal discomfort. A paracentesis has been ordered. Nursing actions would include:
Select all that apply.
32. A client with ascites as a result of hepatitis C is in the emergency department complaining of abdominal discomfort. A paracentesis has been ordered. Nursing actions would include:
Select all that apply.
. Having the client void before the procedure.
. Observing for possible increase in blood pressure during the procedure.
. Positioning the client in semi-Fowler's, head of bed elevated 30 degrees.
. Applying pressure to the injection site following the procedure.
. Allowing fluid to drain from catheter for 24 hours.
. Measuring and recording amount of fluid removed.
Test-Taking Tip
Use a true-and-false approach to choosing the correct answers. Visualize a needle in the abdomen and fluid draining out.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests
. . .
Answer 1 is correct because emptying the bladder before the procedure will reduce the risk of damage to the bladder when the needle is inserted into the peritoneal cavity to drain the fluid. Answer 2 is incorrect because the client may experience low blood pressure and should be monitored for signs of hypovolemic shock during the procedure. This is due to the shift of fluid from the vascular space as the protein-rich ascitic fluid is removed. Answer 3 is incorrect because the desired position is sitting on the side of the bed with feet supported by a chair. If large amounts of fluid are to be removed, the client might be flat. Answer 4 is correct because applying pressure to stop any bleeding following removal of the needle is important. The insertion site should be covered with a sterile dressing. Answer 5 is incorrect because a paracentesis usually takes 20 to 30 minutes and the physician is present during the procedure. The needle is not left in place for 24 hours. Answer 6 is correct because the amount and color of the ascitic fluid is documented and a specimen is sent to the laboratory for analysis before discarding the rest of the fluid.