AND ANSWERS WITH RATIONALES
The healthcare provider performs a paracentesis
on a client with ascites and 3 liters of fluid are
removed. Which assessment parameter is most
critical for the nurse to monitor following the
procedure?
a. Pedal pulses.
b. Breath sounds.
c. Gag reflex.
d. Vital signs - correct answer-ANS: D
Life-threatening complications such as hypovolemia
and sepsis can occur following a paracentesis, and
,measurement of vital signs (D) will provide
assessment data that will help detect the
occurrence of such complications. (A) might be
assessed to check for circulation in the lower
extremities, but are not indicated for
postparacentesis assessment. Reduction of (B) may
occur as the result of decreased fluid in the
peritoneal cavity, but is a desired outcome, not a
complication, of this procedure. (C) is not affected
by a paracentesis procedure
1. While assessing a client with diabetes mellitus,
the nurse observes an absence of hair growth on
,the client's legs. What additional assessment
provides further data to support this finding?
a. Palpate for the presence of femoral pulses
bilaterally.
b. Assess for the presence of a positive Homan's sign.
c. Observe the appearance of the skin on the client's
legs.
d. Watch the client's posture and balance during
ambulation - correct answer-ANS: C Signs of
chronic arterial insufficiency include decreased
hair growth in the legs and feet, absent or
decreased pedal pulses, infection in the foot, poor
wound healing, thickened nails, and a shiny
appearance of the skin (C). Femoral pulses (A)
should still be palpable in the diabetic with chronic
, arterial insufficiency. A positive Homan's sign is an
indicator of deep vein thrombosis (B). (D) would
probably not be affected significantly by chronic
arterial insufficiency.
2. The healthcare provider prescribes 15 mg/kg of
Streptomycin for an infant weighing 4 pounds. The
drug is diluted in 25 ml of D5W to run over 8 hours.
How much Streptomycin will the infant receive?
a. 9 mg.
b. 18 mg.
c. 27 mg.
d. 36 mg - correct answer-ANS: C
4 lbs / 2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C).