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 A
Explanation
a. A sensory warning that a seizure is imminent: An aura is a subjective sensation or warning that a seizure is about to occur. It can manifest as visual, auditory, or other sensory experiences.
b. A brief loss of consciousness accompanied by staring: This describes an absence seizure, not an aura. Absence seizures are characterized by a brief loss of consciousness without convulsions.
c. A continuous seizure state in which seizures occur in rapid succession: This describes status epilepticus, not an aura. Status epilepticus is a medical emergency characterized by prolonged or rapidly recurring seizures.
d. A period of sleepiness following the seizure during which arousal is difficult: This describes the postictal state, not an aura. The postictal state is a period of altered consciousness or
sleepiness that may follow a seizure.
Correct Answer is D
Explanation
a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and
expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.
b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in
asthma exacerbation.
c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma
exacerbation.
d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during
expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.
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