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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.
c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.
d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the
rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.
Correct Answer is B
Explanation
a. Overusing a muscle while jogging: Overuse injuries are more commonly associated with strains, not sprains. Strains involve the muscles or tendons.
b. Twisting a ligament while walking: This is an example of a mechanism that can lead to a sprain. A sprain involves the stretching or tearing of ligaments, which connect bone to bone.
c. Impact injury on a joint from a fall: This is more likely to result in a sprain, as it can cause damage to ligaments.
d. Crush injury to a bone from blunt trauma: This type of injury is more likely to affect bones rather than ligaments or tendons, and it would not be considered a sprain or strain.
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