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. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.
B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.
C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.
D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.
Correct Answer is A
Explanation
a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.
b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.
c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.
d. Administer a prescribed analgesic: Pain management is important postoperatively, but the
immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.
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