Page 1486 - Saunders Comprehensive Review For NCLEX-RN

has not returned, the client could aspirate.
J. Computed tomography (CT) scan
1. Description
a. Noninvasive cross-sectional view that
can detect tissue densities in the
abdomen, including in the liver,
spleen, pancreas, and biliary tree.
b. Can be performed with or without
contrast medium.
2. Preprocedure
a. Client is NPO for at least 4 hours.
b. If contrast medium will be used, assess
for previous sensitivities and allergies.
3. Postprocedure: No specific care is required.

K. Paracentesis

1. Description and preprocedure (see Priority Nursing
Actions)

Priority Nursing Actions

Paracentesis
1. Ensure that the client understands the procedure and that
informed consent has been obtained.
2. Obtain vital signs, including weight, and assist the client to void.
3. Position the client upright.
4. Assist the primary health care provider (PHCP), monitor vital
signs, and provide comfort and support during the procedure.
5. Apply a dressing to the site of puncture.
6. Monitor vital signs, especially blood pressure and pulse, because
these parameters provide information on rapid vasodilation
postparacentesis; weigh the client postprocedure, and maintain
the client on bed rest.
7. Measure the amount of fluid removed.
8. Label and send the fluid for laboratory analysis.
9. Document the event, client’s response, and appearance and
amount of fluid removed.

Reference

Ignatavicius, Workman, Rebar (2018), p. 1177.

2. Postprocedure

a. Monitor vital signs.
b. Measure fluid collected, describe, and record.
c. Label fluid samples and send to the laboratory for
analysis.
d. Apply a dry sterile dressing to the insertion site;
monitor the site for bleeding.
e. Measure abdominal girth and weight.

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