A client with ascites is at risk of developing fluid and electrolyte imbalances. Which nursing intervention should be implemented to monitor the client's fluid balance and hydration status effectively?

Weigh the client daily and record the weight in the chart.

Measure vital signs every four hours to assess for changes.

Assess urine output hourly and document the findings.

Restrict fluid intake to prevent further fluid retention.

Answer and Explanation

The Correct Answer is A

Choice A reason:

This statement is correct. Weighing the client daily and recording the weight in the chart is an essential intervention to monitor fluid balance and detect any changes in body weight, which can indicate fluid retention or loss.

Choice B reason:

Measuring vital signs every four hours is important for assessing the client's overall condition, but it does not directly monitor fluid balance or hydration status.

Choice C reason:

Assessing urine output hourly is important, especially for clients with ascites who may have altered kidney function. However, it may not provide a comprehensive assessment of the client's overall fluid balance.

Choice D reason:

Restricting fluid intake may not be appropriate for all clients with ascites, as fluid restriction could lead to dehydration and further imbalances in fluid and electrolyte levels.

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Correct Answer is D

Explanation

Choice A reason:

Heart failure can lead to fluid retention in the body, but it is not the most common cause of ascites. Liver disease, such as cirrhosis, is the leading cause of ascites.

Choice B reason:

Kidney disease can result in fluid retention, but it is not the primary cause of ascites.

Choice C reason:

Lung cancer is not a common cause of ascites. Liver disease, particularly cirrhosis, is the most prevalent reason for this condition.

Choice D reason:

This statement is correct. Liver disease, particularly cirrhosis, is the leading cause of ascites due to its impact on fluid balance in the body.

A. Regulation of blood glucose levels. B. Maintenance of acid-base balance. C. Production of red blood cells. D. Filtration and excretion of waste products.

Correct Answer is D

Explanation

Choice A reason:

Regulation of blood glucose levels is not a primary function of the kidneys in fluid balance. It is primarily related to the endocrine system and insulin regulation.

Choice B reason:

Maintenance of acid-base balance is a critical function of the kidneys but is not directly related to fluid balance leading to ascites.

Choice C reason:

Production of red blood cells occurs in the bone marrow, not the kidneys. While the kidneys produce erythropoietin, a hormone that stimulates red blood cell production, this is not the primary function related to fluid balance.

Choice D reason:

This statement is correct. The kidneys' primary function related to fluid balance is filtration and excretion of waste products and excess fluid, which helps maintain proper fluid balance in the body. In chronic kidney disease (CKD), impaired kidney function can lead to fluid retention and contribute to the development of ascites.

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A client with ascites is at risk of developing fluid and electrolyte imbalances. Which nursing intervention should be implemented to monitor the client's fluid balance and hydration status effectively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education to a client newly diagnosed with ascites. The client asks about the most common underlying cause of this condition. Which of the following responses by the nurse is accurate?

Correct Answer is D

Explanation

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:

Correct Answer is D

Explanation

A nurse is providing education to a client newly diagnosed with ascites. The client asks about the underlying cause of this condition. Which of the following responses by the nurse is accurate?

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

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?

A nurse is educating a client with cirrhosis about measures to prevent ascites exacerbation. Which of the following instructions should the nurse include in the teaching?

A client with severe ascites is undergoing therapeutic paracentesis. After the procedure, the nurse should monitor the client for which of the following complications?

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 nurse is providing dietary education to a client with ascites. Which of the following dietary restrictions should the nurse emphasize to reduce fluid accumulation in the abdominal cavity?

A client with ascites is experiencing respiratory distress and difficulty breathing. The nurse should prioritize which of the following nursing interventions?