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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
Pain located in the right lower quadrant is typically associated with conditions such as appendicitis, not diverticulitis.
Choice B rationale
Diverticulitis is often associated with cramping, constant pain in the left lower quadrant. This is because the most common site of diverticula, small bulging pouches that can form in the lining of the digestive system, is in the sigmoid and descending colon, which are located in the left lower quadrant of the abdomen.
Choice C rationale
Sudden onset of pain 2 hours ago is not typically indicative of diverticulitis. While diverticulitis pain can be sudden, it usually worsens over several days.
Choice D rationale
Diarrhea for the past 3 days is not specifically indicative of diverticulitis. While changes in bowel habits can occur with diverticulitis, it is not a defining symptom.

A. Observe mucous membranes for dryness B. Provide frequent oral care with moist swabs C. Offer the client small sips of water D. Increase the rate of intravenous (IV) fluids

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Observing mucous membranes for dryness can indicate dehydration.
Choice B rationale

Providing frequent oral care with moist swabs can help alleviate the discomfort of a dry mouth due to NPO status.
Choice C rationale
Offering the client small sips of water is not appropriate as the client is on a diet of nothing by mouth (NPO) except ice chips.
Choice D rationale
Increasing the rate of intravenous (IV) fluids can help prevent dehydration.

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A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is gathering information from a patient with abdominal pain. Which description of pain is consistent with diverticulitis?

Correct Answer is B

Explanation

The nurse is caring for a client who received a new diet prescription from the physician for nothing by mouth (NPO) except ice chips. Which actions would the nurse take to alleviate the effects of dehydration? Select all that apply

Correct Answer is ["A","B","D"]

Explanation

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A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites.
What action should the nurse take?