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 A
Explanation
Choice A rationale
After a Roux-en-Y surgical procedure, patients are typically put on a liquid-only diet for the first week or two after surgery. Over the next month, they are able to add soft food and eventually regular food back into their diet. Given that the patient is only one day postoperative, the consumption of solid foods like strawberry yogurt could potentially lead to
complications such as dumping syndrome, which is a group of symptoms that includes vomiting, nausea, and dizziness. It occurs when food moves from your stomach into your small intestine too quickly.
Choice B rationale
Chicken broth is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice C rationale
Apple juice is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice D rationale
Iced tea is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Correct Answer is A
Explanation
Choice A rationale
A clear liquid diet may not provide adequate nutrition for a patient with peritonitis. Peritonitis, an inflammation of the peritoneum, can be caused by infection, including from bacteria or fungi, or by a rupture in the abdomen. It’s a serious condition that requires immediate treatment, often including antibiotics and surgery.
Choice B rationale
Nasogastric tube insertion can be a part of the management for peritonitis. It can help decompress the stomach and relieve symptoms such as nausea and vomiting.
Choice C rationale
Intravenous antibiotics are typically a part of the treatment plan for peritonitis, as the condition is often caused by an infection.
Choice D rationale
Strict intake and output monitoring is important in the management of peritonitis. It helps assess the patient’s fluid balance and response to treatment.
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