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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

Muscle weakness and fatigue are not commonly associated with spironolactone use.

Choice B reason:

Increased urine output and dehydration may occur with diuretics, but spironolactone is a potassium-sparing diuretic, so excessive urine output and dehydration are less likely to occur with this medication.

Choice C reason:

Hypotension and dizziness are potential side effects of some diuretics, but they are not specific to spironolactone use.

Choice D reason:

This statement is correct. Spironolactone is a potassium-sparing diuretic, which means it can lead to hyperkalemia (elevated potassium levels) if not monitored carefully. Hyperkalemia can cause irregular heart rhythms and other serious complications.

A. Encouraging the client to lie flat in bed to reduce pressure on the abdomen. B. Administering laxatives to promote bowel movements and relieve bloating. C. Assisting the client with regular and gentle ambulation to facilitate fluid movement. D. Applying cold packs to the abdomen to reduce inflammation and swelling.

Correct Answer is C

Explanation

Choice A reason:

Encouraging the client to lie flat in bed may worsen abdominal distention and discomfort. It is better to promote positions that facilitate fluid drainage, such as elevating the head of the bed or placing the client in a side-lying position.

Choice B reason:

Administering laxatives may not be appropriate for ascites management and could lead to electrolyte imbalances. It is essential to manage bowel movements cautiously, considering the client's fluid and electrolyte status.

Choice C reason:

This statement is correct. Assisting the client with regular and gentle ambulation can help facilitate fluid movement and reduce abdominal distention. Movement helps stimulate peristalsis and may improve drainage of fluid from the abdominal cavity.

Choice D reason:

Applying cold packs to the abdomen may provide temporary relief for localized pain but will not directly address the underlying issue of ascites or reduce abdominal distention.

View Question and Answer

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

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 ascites is prescribed spironolactone, a potassium-sparing diuretic. The nurse instructs the client to monitor for which of the following adverse effects while taking this medication?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

A client with suspected ascites is scheduled for paracentesis. The nurse explains to the client that this procedure involves:

A client with hepatitis C asks the nurse about the risk of developing ascites. Which of the following factors related to hepatitis C may increase the client's likelihood of developing ascites?

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 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 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 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 ascites presents with difficulty breathing and increased respiratory rate. The nurse should recognize these symptoms as a potential complication of ascites known as:

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?