During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fluid output (Option C). This is the most appropriate response because after a paracentesis, it is essential to monitor the drainage output to assess the client's response to the procedure and to watch for any signs of complications. Option A, palpating for abdominal distention, is not the priority in this situation as monitoring fluid output takes precedence to ensure proper drainage and assess for complications. Option B, sending the fluid to the lab for analysis, may be necessary at some point, but the immediate action should be to monitor the fluid output to ensure proper drainage and assess for any immediate concerns. Option D, clamping the drainage tube for 5 minutes, is not recommended as it may lead to a potential buildup of fluid in the abdomen, which could result in discomfort and complications for the client. From an educational standpoint, understanding the importance of monitoring post-procedural drainage output is crucial in pediatric nursing, especially in cases like ascites where fluid removal plays a significant role in managing the client's condition. Nurses must prioritize ongoing assessment and monitoring to ensure optimal patient outcomes and prevent potential complications.

Correct Answer: A

Rationale: The correct answer is A) Invite friends over regularly to share in meal times. This option is the best choice because it addresses a potential psychosocial factor contributing to the weight loss of the client with Parkinson's disease. Parkinson's disease can lead to social isolation, depression, and decreased appetite, which can all contribute to weight loss. By inviting friends over for meals, the client is more likely to have social interaction, which can improve mood and appetite. Option B) Encouraging the client to drink clear liquids between meals does not directly address the underlying issue of weight loss in Parkinson's disease. While hydration is important, it does not specifically target the potential causes of weight loss in this case. Option C) Coaching the client to make an intentional effort to swallow is not the most appropriate response as it assumes the weight loss is solely due to swallowing difficulties, which may not be the case for this client. Option D) Talking to the healthcare provider about prescribing an appetite stimulant should be considered if other interventions do not work; however, it should not be the first line of action. Encouraging social interaction and a supportive environment during meals can be more effective in addressing weight loss in this situation. In an educational context, understanding the multifactorial nature of weight loss in clients with Parkinson's disease is crucial for nurses caring for these individuals. Providing holistic care that addresses not only physical symptoms but also psychosocial aspects can lead to better outcomes for the client.

Correct Answer: C

Rationale: In the scenario of a client with a liver abscess undergoing surgical evacuation and drainage, the most important laboratory value for the nurse to monitor following the procedure is the white blood cell count (WBC). Rationale for selecting white blood cell count (WBC): 1. Infections, such as a liver abscess, trigger an inflammatory response leading to an increase in WBC count, specifically neutrophils. Monitoring the WBC count post-surgery helps assess the body's response to the infection and the effectiveness of treatment. Reasons for eliminating other options: A) Serum creatinine: While important for assessing kidney function, it is not directly related to monitoring for post-surgical complications of a liver abscess. B) Blood urea nitrogen (BUN): Primarily indicates kidney function and hydration status, not the immediate concern post-surgical drainage of a liver abscess. D) Serum glucose: Monitoring glucose levels is crucial in diabetic patients or those at risk of hypoglycemia, but it is not the priority in this scenario. Educational context: Understanding the rationale behind monitoring specific laboratory values post-surgery is crucial for nurses caring for pediatric patients with cardiovascular disorders. This knowledge ensures timely identification of complications, appropriate interventions, and improved patient outcomes. Regular assessment and interpretation of laboratory values are essential skills for pediatric nurses to provide safe and effective care.

Correct Answer: A

Rationale: In this scenario, the correct assessment data the nurse should obtain next is blood pressure (Option A). Pheochromocytoma is a catecholamine-secreting tumor that can cause severe hypertension, leading to symptoms such as severe headaches and diaphoresis. Monitoring the client's blood pressure is crucial in this situation to assess for hypertensive crisis, which can be life-threatening if not managed promptly. Blood glucose level (Option B) is not the priority in this case as the client's symptoms are more indicative of a cardiovascular issue related to pheochromocytoma rather than a metabolic issue. Respiratory rate (Option C) and oxygen saturation (Option D) are important assessments, but in this context, the client's presentation of severe headache and diaphoresis points more towards a cardiovascular concern related to the pheochromocytoma. However, respiratory rate and oxygen saturation should still be monitored as part of the overall assessment. Educationally, understanding the specific signs and symptoms of pheochromocytoma and related cardiovascular disorders in pediatric patients is crucial for nurses working in pediatric settings. This rationale highlights the importance of prioritizing assessments based on the client's presenting symptoms to provide timely and appropriate care.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) 30 ml/hour. To understand why, let's break down the calculation. The IV solution contains 100 units of regular insulin in 250 ml of 0.45% saline. The prescribed infusion rate is 12 units/hour. To find out how many ml of the solution must be infused per hour, we can set up a proportion: 100 units = 250 ml 12 units = x ml Cross multiplying, we get: 100x = 250 * 12 x = 250 * 12 / 100 x = 30 ml/hour Therefore, the nurse should program the infusion pump to deliver 30 ml/hour. Now, let's analyze why the other options are incorrect: - Option B) 3 ml/hour: This is too low and does not match the calculation. - Option C) 40 ml/hour: This is too high and does not align with the calculation. - Option D) 15 ml/hour: This value is not derived from the correct calculation and is therefore incorrect. In an educational context, understanding how to calculate medication dosages and infusion rates is crucial for pediatric nurses to ensure safe and effective care for their young patients. This type of question tests the nurse's ability to perform dosage calculations accurately, which is a fundamental skill in pediatric pharmacology and nursing practice. Nurses must be proficient in dosage calculations to prevent medication errors and ensure optimal patient outcomes.