A nurse is preparing a client with cirrhosis for a bedside paracentesis to relieve severe ascites. To reduce the risk of procedural complications and establish an accurate baseline for post-procedure evaluation, in what order should the nurse complete the following actions? Arrange the steps from first to last.
- 1Verify that the informed consent document has been signed and witnessed.
- 2Instruct the client to completely empty their urinary bladder.
- 3Obtain the client's baseline vital signs, weight, and abdominal girth.
- 4Position the client sitting upright on the edge of the bed with feet supported.
Cevap
The correct sequence is: Verify informed consent, instruct the client to empty their bladder, obtain baseline measurements, and finally position the client upright on the edge of the bed.
This sequence ensures legal safety, physical safety, accurate baseline data, and procedural readiness. Verifying consent is always the first administrative step. Emptying the bladder is the most critical physical safety step to prevent accidental puncture. Baseline measurements must be taken after the bladder is empty to ensure accuracy. Finally, positioning the client upright uses gravity to pool the fluid in the lower abdomen for safe removal.
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Anahtar Kavram
When preparing a client for a paracentesis, the primary risk reduction strategy is ensuring the bladder is completely empty to prevent perforation. Accurate baseline measurements must follow voiding, and the client is then positioned upright to facilitate gravity drainage.
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