A nurse is preparing a client with ascites for a bedside abdominal paracentesis. In which order should the nurse perform the following actions to ensure the client's safety and reduce the risk of physiological complications? Arrange the actions in the correct chronological sequence.
- 1Verify that the client has signed the informed consent document.
- 2Instruct the client to empty their bladder completely.
- 3Obtain the client's baseline vital signs, weight, and abdominal girth.
- 4Position the client upright in high Fowler's or sitting on the edge of the bed.
Cevap
The correct sequence is to first verify informed consent, then instruct the client to void, followed by obtaining baseline measurements, and finally positioning the client upright for the procedure.
Preparing a client for a paracentesis requires a deliberate, sequential approach focused on risk reduction. First, the nurse must ensure legal consent is obtained. Next, instructing the client to void is the most critical physiological safety step to prevent accidental bladder injury. Once the bladder is empty, accurate baselines (vital signs, dry weight, abdominal girth) are recorded to later assess fluid shifts and signs of hemodynamic instability. Finally, positioning the client upright uses gravity to safely pool fluid in the lower abdomen, keeping floating bowel loops and the decompressed bladder away from the insertion site.
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Anahtar Kavram
Prioritization of safety and risk reduction interventions during preparation for an invasive procedure (paracentesis).