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. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin
secretions in a client with a tracheostomy.
b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.
c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.
d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing
humidified oxygen is a more appropriate approach.
Correct Answer is D
Explanation
a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.
b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.
c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.
d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.
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