A nurse is preparing a client with cirrhosis for a bedside paracentesis to relieve severe ascites. Which nursing actions are essential to reduce the client's risk for procedural and post-procedural complications? Select all that apply.
- Instruct the client to void completely immediately before the provider begins the procedure.Answer
- Measure the client's baseline weight, abdominal girth, and vital signs before fluid removal.Answer
- CPlace the client in a flat, supine position to help the ascitic fluid pool centrally.
- DPalpate the abdomen for areas of tenderness before auscultating bowel sounds during the initial assessment.
- Monitor the client closely for early indicators of hypovolemic shock, such as tachycardia and a narrowing pulse pressure.Answer
Answer
The correct actions include instructing the client to void, obtaining baseline measurements, and monitoring for signs of hypovolemic shock.
The correct actions directly minimize the risk of iatrogenic injury (such as bladder puncture), establish necessary baselines for post-procedure comparison, and ensure the early detection of potentially fatal complications like hypovolemic shock following large-volume fluid shifts.
Step-by-Step Solution
Key Concept
Paracentesis Safety and Risk Reduction