A client with ascites is experiencing respiratory distress and difficulty breathing. The nurse should prioritize which of the following nursing interventions?
Administering prescribed diuretics to reduce fluid volume.
Elevating the head of the bed to improve respiratory mechanics.
Providing oxygen therapy to enhance oxygen saturation.
Encouraging the client to perform deep breathing exercises.
The Correct Answer is B
Choice A reason:
Administering prescribed diuretics is essential in managing ascites, but it may not immediately address the client's respiratory distress.
Choice B reason:
This statement is correct. Elevating the head of the bed can improve respiratory mechanics and ease breathing for a client experiencing respiratory distress due to ascites.
Choice C reason:
Providing oxygen therapy is important for clients with respiratory distress, but it may not directly address the underlying cause of the distress in this situation.
Choice D reason:
Deep breathing exercises are beneficial for promoting lung expansion, but they may not be the priority in a client experiencing severe respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason:
Coughing and wheezing during physical activity are typical symptoms of congestive heart failure (CHF), but they do not directly indicate the presence of ascites.
Choice B reason:
Rapid and irregular heart rate at rest is a common manifestation of congestive heart failure (CHF) but does not directly indicate the presence of ascites.
Choice C reason:
This statement is correct. Ascites is characterized by the accumulation of fluid in the abdominal cavity, leading to swelling and distention in the lower abdomen.
Choice D reason:
Cold and clammy extremities are not typical manifestations of ascites and are not directly related to fluid overload in congestive heart failure (CHF).
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