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 D
Explanation
a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be
reported to the provider.
Correct Answer is B
Explanation
a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between
inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.
b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.
c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.
d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.
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