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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Bradycardia: Atenolol is a beta-blocker that can slow down the heart rate, leading to
bradycardia. Monitoring the client for signs of bradycardia, such as dizziness, fatigue, or fainting, is important.
b. Anemia: Atenolol is not known to cause anemia. Monitoring for anemia is not a specific concern with this medication.
c. Hypokalemia: Atenolol is not associated with causing hypokalemia. However, beta-blockers in general may affect potassium levels indirectly.
d. Neutropenia: Atenolol is not typically associated with causing neutropenia. Monitoring for neutropenia is not a specific concern with this medication.
Correct Answer is A
Explanation
a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.
b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and
withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.
c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.
d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper
measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.
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