The nurse is preparing a client for a bedside abdominal paracentesis. In what order should the nurse perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.
- 1Verify that the informed consent form has been signed by the client.
- 2Instruct the client to empty their bladder completely.
- 3Obtain and record baseline vital signs, weight, and abdominal girth.
- 4Position the client sitting upright on the edge of the bed or in high Fowler's position.
Cevap
The correct sequence is to first verify informed consent, then instruct the client to void, followed by obtaining baseline data, and finally positioning the client upright.
The proper sequence prioritizes legal requirements first, followed by anatomical risk reduction, baseline assessment, and finally procedural positioning. Verifying consent is always the initial action. Having the client void decreases bladder size, which is a critical safety step to reduce perforation risk. Baseline data is then collected (weight is most accurate after voiding) to monitor for subsequent fluid shifts or shock. Finally, the upright position allows ascitic fluid to pool in the lower abdomen for safe removal.
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Anahtar Kavram
Preparation for a paracentesis focuses on legal authorization, anatomical safety (emptying the bladder to prevent perforation), baseline assessment for monitoring complications, and proper positioning to facilitate the procedure.