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 C

Explanation

a. Droplet precautions: Droplet precautions are used for diseases that are transmitted by

respiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.

b. Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.

c. Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.

d. Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is not

transmitted through contact with intact skin.

A. Urinary retention B. Urinary incontinence C. Urinary frequency D. Urinary tract infection

Correct Answer is D

Explanation

a. Urinary retention: Dark amber, cloudy, and malodorous urine is not typically associated with urinary retention. Urinary retention usually results in a lower-than-normal urine output.

b. Urinary incontinence: Incontinence refers to the inability to control urine flow and does not directly cause changes in urine color, clarity, or odor.

c. Urinary frequency: Increased frequency of urination is not typically associated with dark amber, cloudy, and malodorous urine.

d. Urinary tract infection (UTI): Dark amber, cloudy, and foul-smelling urine are common signs of a urinary tract infection. The infection causes changes in the appearance and odor of urine due to the presence of bacteria and inflammatory cells.

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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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