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 C

Explanation

Choice A reason:

Increased liver enzyme levels are not directly related to the abdominal pain and discomfort experienced by the client with ascites. Elevated liver enzymes indicate liver damage, but they do not cause abdominal pain.

Choice B reason:

Gallstone formation in the gallbladder is not directly related to the abdominal pain and discomfort experienced by the client with ascites.

Choice C reason:

This statement is correct. The abdominal pain and discomfort experienced by the client with ascites are primarily due to the stretching of the abdominal wall from the accumulation of fluid in the abdominal cavity.

Choice D reason:

Inflammation of the pancreas (pancreatitis) is not directly related to the abdominal pain and discomfort experienced by the client with ascites.

A. Pleural effusion. B. Pneumonia. C. Pulmonary edema. D. Atelectasis.

Correct Answer is C

Explanation

Choice A reason:

Pleural effusion is fluid accumulation in the pleural cavity (around the lungs), and it can be associated with ascites, but it is not the specific complication described in the scenario.

Choice B reason:

Pneumonia is a lung infection and is not directly related to the difficulty breathing and increased respiratory rate described in the client with ascites.

Choice C reason:

This statement is correct. Pulmonary edema is a potential complication of ascites in which excess fluid accumulates in the lungs, leading to difficulty breathing and an increased respiratory rate.

Choice D reason:

Atelectasis is the collapse of part or all of a lung, and while it can be associated with difficulty breathing, it is not directly related to 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 client with liver cirrhosis and ascites is experiencing abdominal pain and discomfort. The nurse should recognize that this pain is primarily due to:

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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