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.

Answer and Explanation

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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Correct Answer is C

Explanation

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

A. Type A B. Type B C. Type O D. Type AB

Correct Answer is C

Explanation

a. Type A: Type A blood may not be compatible with the client's blood type, and it is not considered a universal donor.

b. Type B: Similar to Type A, Type B blood may not be compatible with the client's blood type, and it is not considered a universal donor.

c. Type O: Type O negative blood is considered the universal donor for packed red blood cells. It can be administered to individuals with any blood type in an emergency situation.

d. Type AB: While Type AB is considered the universal recipient for blood transfusions, it is not the universal donor.

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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?

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Naxlex Comprehensive Predictor Exams

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