A client with ascites is admitted to the hospital. The nurse is assessing the client for potential complications related to fluid retention. Which of the following findings would be most concerning and require immediate intervention?

Mild ankle edema.

Moderate abdominal distention.

Complaints of thirst and dry mouth.

Respiratory distress and cyanosis.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Mild ankle edema is not uncommon in clients with fluid retention, such as ascites. While it requires monitoring, it does not indicate an immediate need for intervention.

Choice B reason:

Moderate abdominal distention is a common finding in clients with ascites and should be monitored, but it does not require immediate intervention.

Choice C reason:

Complaints of thirst and dry mouth may indicate dehydration, which should be addressed, but it does not require immediate intervention as other options.

Choice D reason:

This statement is correct. Respiratory distress and cyanosis are concerning findings in a client with ascites, as they may indicate severe pulmonary edema or other respiratory complications that require immediate intervention and medical attention.

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Correct Answer is B

Explanation

Choice A reason:

Increased urine output and dehydration are not typical findings in clients with ascites. Ascites involves fluid accumulation in the abdominal cavity, not fluid loss through the urinary system.

Choice B reason:

This statement is correct. Visible abdominal swelling and distention are characteristic signs of ascites, indicating the accumulation of fluid in the abdominal cavity.

Choice C reason:

Dry, cracked skin and itching are not specific to ascites and may be related to other conditions such as skin disorders or dehydration.

Choice D reason:

Rapid and irregular heart rate is not directly related to ascites. It may be associated with other conditions such as heart disease or infection.

A. Administering diuretics to increase urine output. B. Elevating the head of the bed to promote respiratory function. C. Encouraging deep breathing exercises to improve lung capacity. D. Placing the client in a side-lying position to facilitate fluid drainage.

Correct Answer is D

Explanation

Choice A reason:

Administering diuretics may be part of the management plan, but it may not provide immediate relief to the client experiencing discomfort and difficulty breathing.

Choice B reason:

Elevating the head of the bed can help improve respiratory function, but placing the client in a side-lying position is more effective for facilitating fluid drainage from the abdomen and providing immediate relief to the client with ascites.

Choice C reason:

Deep breathing exercises are beneficial for improving lung capacity, but they may not provide immediate relief to the client experiencing discomfort and difficulty breathing due to ascites.

Choice D reason:

This statement is correct. Placing the client in a side-lying position helps to facilitate fluid drainage from the abdomen and can provide immediate relief to the client with ascites who is experiencing discomfort and difficulty breathing.

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A client with ascites is admitted to the hospital. The nurse is assessing the client for potential complications related to fluid retention. Which of the following findings would be most concerning and require immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with suspected ascites. Which of the following findings would the nurse expect to observe during the physical examination?

Correct Answer is B

Explanation

A client with ascites is experiencing discomfort and difficulty breathing due to fluid accumulation in the abdomen. What intervention should the nurse prioritize to provide immediate relief to the client?

Correct Answer is D

Explanation

A client with liver cirrhosis and ascites is experiencing abdominal pain and discomfort. The nurse should recognize that this pain is primarily due to:

A nurse is providing care to a client with ascites. Which intervention is essential for the nurse to implement to promote comfort and reduce abdominal distention?

A client with ascites is being monitored for signs of fluid accumulation and complications. The nurse should assess for which of the following early signs of ascites progression?

A client with chronic kidney disease (CKD) is at risk of developing ascites due to impaired fluid regulation. The nurse explains that the kidneys' primary function related to fluid balance is:

A client with chronic alcohol abuse is at risk of developing ascites. The nurse explains that excessive alcohol consumption can contribute to ascites primarily by causing:

A nurse is assessing a client with ascites. The nurse notices that the client's abdomen is distended, and the skin over the abdomen is taut and shiny. Which intervention should the nurse prioritize based on this assessment finding?

A client with congestive heart failure (CHF) is at risk of developing ascites due to fluid overload. Which of the following manifestations may indicate the presence of ascites in this client?

A client with cirrhosis and ascites is receiving medical treatment to manage the fluid accumulation. The client asks the nurse about lifestyle changes that may help improve the condition. Which of the following responses by the nurse is accurate?