A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

Position the client flat in bed.

Weigh the client weekly.

Medicate the client with acetaminophen for discomfort.

Measure the client’s abdominal girth every 8 hours.

Answer and Explanation

The Correct Answer is D

a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.

b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.

c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.

d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.

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Correct Answer is A

Explanation

a.The statement "I will drink plenty of fluids after the test" indicates the client's understanding that hydration is important after the procedure, which is also a crucial aspect of post-procedure care. This response suggests the client understands the need to stay hydrated after ingesting barium, which helps eliminate the contrast material from the body and prevents constipation.

b. “I will expect my stool to be black after this procedure.”: The statement is related to the potential side effects of barium, but it does not address the pre-test instructions.

c. “I will expect a warm feeling when the dye is injected.”: This statement may relate to the sensation during the test but does not address the pre-test instructions.

d.while fasting may be required before the test, a clear liquid diet is not typically maintained for 24 hours prior to the procedure.

A. Allow the client to take her morning vitamins. B. Allow the client to keep her tongue stud in. C. Allow the client to keep her hearing aids in. D. Allow the client to consume clear liquids up to the time of surgery.

Correct Answer is C

Explanation

a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.

b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are

usually removed before surgery to prevent interference with equipment and to ensure patient safety.

c. Allow the client to keep her hearing aids in: It is important for the client with a hearing

impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.

d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard

preoperative fasting guidelines.

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A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

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