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:

Electrolyte imbalances can occur in clients with ascites, but they are not directly related to the symptoms of fatigue and weakness described by the client.

Choice B reason:

Iron deficiency anemia may be present in clients with chronic liver disease, but it is not the primary cause of the client's fatigue and weakness in this scenario.

Choice C reason:

Hepatic encephalopathy is a complication of liver disease, but it typically presents with neurological symptoms such as confusion, altered mental status, and behavior changes, not fatigue and weakness.

Choice D reason:

This statement is correct. Fatigue and weakness are common symptoms in clients with chronic liver disease and ascites, and they can be related to malnutrition, which is often seen in these clients due to poor appetite, nutrient malabsorption, and other factors related to liver dysfunction.

A. Magnetic Resonance Imaging (MRI). B. Electroencephalogram (EEG). C. Positron Emission Tomography (PET) scan. D. Bone Density Scan (DEXA scan).

Correct Answer is A

Explanation

Choice A reason:

This statement is correct. Magnetic Resonance Imaging (MRI) is commonly used to evaluate the liver and abdominal organs, providing detailed images that can help assess the severity and extent of ascites in clients with cirrhosis.

Choice B reason:

An electroencephalogram (EEG) is used to assess brain activity and is not directly related to the evaluation of ascites in clients with cirrhosis.

Choice C reason:

Positron Emission Tomography (PET) scan is used to visualize metabolic activity in body tissues and is not commonly used for evaluating ascites.

Choice D reason:

Bone Density Scan (DEXA scan) is used to assess bone health and is not directly related to the evaluation of ascites in clients with cirrhosis.

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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 chronic liver disease and ascites reports feeling fatigued and weak. The nurse should recognize these symptoms as potential manifestations of:

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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