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 D
Explanation
Choice A rationale
Chlorhexidine is an antiseptic that is used for cleaning the skin or the hands and helps to prevent infections caused by bacteria. However, it is not the recommended cleansing agent for hand hygiene in a Clostridium difficile infection.
Choice B rationale
Alcohol-based antiseptics are commonly used for hand hygiene in healthcare settings. However, they are not effective against Clostridium difficile spores.
Choice C rationale
Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It may not be effective against Clostridium difficile spores.
Choice D rationale
Soap and water are recommended for hand hygiene when caring for a patient with a Clostridium difficile infection. This is because soap and water are effective in removing C. difficile spores from hands.
Correct Answer is C
Explanation
Choice A rationale
Monitoring peripheral pulses every 8 hours is not typically a priority in the care plan for a patient with acute pancreatitis. While cardiovascular monitoring is important in all patients, it is not specifically related to the management of acute pancreatitis.
Choice B rationale
Measuring urine output every 4 hours can be important in assessing fluid balance and kidney function, but it is not the primary intervention in the care plan for a patient with acute pancreatitis.
Choice C rationale
Maintaining NPO (nothing by mouth) status is a key intervention in the management of acute pancreatitis. This helps to rest the pancreas and reduce the production of digestive enzymes.
Choice D rationale
Ambulating the patient three times daily is generally a good practice for postoperative recovery, but it is not specific to the care of a patient with acute pancreatitis. In the acute phase of pancreatitis, rest is often recommended.
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