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 ["A","B","C"]

Explanation

Choice A rationale
Maintaining bed rest for 48 hours following surgery is a common practice to allow the body to heal and recover.
Choice B rationale

Irrigating the nasogastric tube every 4 to 8 hours is necessary to maintain patency and prevent blockage.
Choice C rationale
Encouraging hourly use of an incentive spirometer while awake can help prevent postoperative complications such as pneumonia and atelectasis.
Choice D rationale
Performing leg exercises every 2 hours is not typically included in the plan of care for a client who had surgery for a bowel obstruction and has a nasogastric tube in place.

A. No stool noted in the collection bag B. Bluish-Purplish colored stoma C. Edematous stoma D. Slight bleeding of the stoma site

Correct Answer is B

Explanation

Choice A rationale
No stool noted in the collection bag is not an immediate concern as it can take several days for the bowel to start functioning after surgery.
Choice B rationale

A bluish-purplish colored stoma could indicate inadequate blood supply to the stoma, which is a medical emergency and should be reported to the provider immediately.
Choice C rationale
An edematous stoma is a common finding in the immediate postoperative period.
Choice D rationale
Slight bleeding of the stoma site can be a normal finding after colostomy placement.

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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

A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction. The client has a nasogastric tube in place.Which of the following actions should the nurse include in the client’s plan of care? (Select all that apply)

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

Explanation

A nurse is collecting data from a client who is 12 hr postoperative following a colectomy with colostomy placement. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a 45-year-old male client in the emergency department who reports severe abdominal pain. Exhibits Based on the information provided, which of the following provider’s prescriptions are anticipated, nonessential, or contraindicated for the client? Select one response per row.

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A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

The nurse provides education for a patient about the treatment for acute gastritis. Which patient statement requires correction by the nurse?

A nurse is collecting data from a patient who has an obstruction and inflammation of the common bile duct due to cholelithiasis. Which finding is expected for this condition?

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A nurse is educating a client with Crohn’s disease about dietary choices. Which food should the nurse recommend as part of the diet?

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