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 B
Explanation
a. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.
b. Breathe in through her nose and out through pursed lips: This technique helps maintain
positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.
c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining
respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.
d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.
Correct Answer is D
Explanation
a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
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