A practical nurse is preparing a client who is scheduled for an abdominal paracentesis to treat severe ascites. In what order should the nurse perform the following preparatory actions? Arrange the steps from first to last.
- 1Verify that the informed consent document has been signed.
- 2Instruct the client to empty their bladder completely.
- 3Measure baseline vital signs and abdominal girth.
- 4Assist the client into a sitting position on the edge of the bed.
Answer
The correct sequence of actions is to first verify informed consent, then have the client empty their bladder, followed by obtaining baseline measurements, and finally positioning the client upright.
The standard of care for assisting with a paracentesis dictates a specific logical flow to ensure client safety. Administrative and legal checks (consent) must occur first. Next, the client must empty their bladder while they are still ambulatory or easily movable to eliminate the primary procedural risk (bladder puncture). Once the bladder is empty, true baseline measurements of weight, girth, and vital signs can be taken immediately prior to the intervention. Finally, the client is placed in the optimal anatomical position (upright) for the provider to begin the sterile procedure.
Step-by-Step Solution
Key Concept
Preparation for a paracentesis requires specific risk reduction measures, most notably having the client empty their bladder to prevent accidental puncture, and establishing vital sign baselines to monitor for subsequent hypovolemia.
Estimated Time:1m 0s