A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites.
What action should the nurse take?
Weigh the patient weekly.
Position the patient flat in bed.
Measure the patient’s abdominal girth every 8 hours.
Administer acetaminophen for discomfort.
The Correct Answer is C
Choice A rationale
Weighing the patient weekly may not be sufficient in the case of cirrhosis with ascites. Fluid accumulation can occur rapidly, and more frequent weight checks may be necessary.
Choice B rationale
Positioning the patient flat in bed is not typically recommended for patients with ascites, as this can increase pressure on the diaphragm and make breathing more difficult.
Choice C rationale
Measuring the patient’s abdominal girth every 8 hours is a common nursing intervention for patients with ascites. It allows for monitoring of fluid accumulation in the abdomen.
Choice D rationale
While managing discomfort is important, acetaminophen should be used cautiously in patients with liver disease, as the liver is involved in drug metabolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Condition A is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice B rationale
Condition B is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice C rationale
Condition C, also known as pernicious anemia, is associated with a risk for vitamin B12 deficiency. This condition impairs the body’s ability to absorb vitamin B12 from the gastrointestinal tract.
Choice D rationale
Condition D is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins
Correct Answer is A
Explanation
Choice A rationale
Asking the patient to share their concerns allows the nurse to understand the patient’s perspective and provide individualized care. It opens up a dialogue where the patient can express their fears and the nurse can provide reassurance and information.
Choice B rationale
While it’s true that many people worry about managing an ileostomy at first, this response does not address the patient’s specific concerns. It’s important to understand the patient’s individual fears and worries.
Choice C rationale
This response may be misleading. While an ileostomy can help manage the symptoms of ulcerative colitis, it does not cure the disease. It’s important to provide accurate information to the patient.
Choice D rationale
Discussing strategies to adapt to life with an ileostomy can be helpful, but it’s important to first understand the patient’s specific concerns. This response assumes what the patient needs without asking them.
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