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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Related Questions
Correct Answer is C
Explanation
a. An endometrial biopsy: An endometrial biopsy is not the preferred method for detecting cervical cancer. It is more commonly used to evaluate the endometrium.
b. CA 125: CA 125 is a tumor marker used more for ovarian cancer detection and monitoring, not cervical cancer.
c. Papanicolaou test: The Papanicolaou test, also known as a Pap smear, is the preferred method for detecting cervical cancer and precancerous changes.
d. Transvaginal ultrasound: While ultrasound may be used to evaluate gynecological conditions,
it is not the primary method for detecting cervical cancer; the Pap smear is the standard screening test.
Correct Answer is B
Explanation
a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and
swallowing difficulties.
b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.
c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.
d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.
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