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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This statement is correct. Endoscopy can be used to visualize the upper gastrointestinal tract and assess for potential sources of bleeding or varices in the esophagus, which can be related to ascites in clients with liver disease.
Choice B reason:
Cardiac catheterization is used to assess the heart and blood vessels and is not directly related to determining the underlying cause of ascites.
Choice C reason:
Lumbar puncture is performed to obtain cerebrospinal fluid for diagnostic purposes and is not typically used to evaluate ascites.
Choice D reason:
Pulmonary function tests are used to assess lung function and are not directly related to determining the underlying cause of ascites.
Correct Answer is C
Explanation
Choice A reason:
Withholding all oral medications on the day of the procedure may not be necessary and should be determined by the healthcare provider's instructions based on the specific medications the client is taking.
Choice B reason:
Administering an analgesic to the client before the procedure may be appropriate to relieve pain, but it should be prescribed and administered by the healthcare provider.
Choice C reason:
This statement is correct. Ensuring that the client has emptied the bladder before the paracentesis procedure is important to prevent any potential complications during the procedure.
Choice D reason:
Fasting for at least 12 hours before the procedure may not be necessary for a paracentesis, as it is typically a minor procedure and does not require prolonged fasting.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.