A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?

Monitor intake and output.

Provide a low-sodium diet.

Increase oral fluid intake.

Weigh the patient daily.

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring intake and output is important in managing cirrhosis and ascites, as it helps track fluid balance and detect early signs of fluid retention. However, this action alone does not directly decrease the presence of ascites. It is more of a monitoring tool than an intervention that reduces fluid accumulation.

Choice B reason: Providing a low-sodium diet is a key intervention to decrease the presence of ascites in patients with cirrhosis. Sodium restriction helps prevent fluid retention by reducing the amount of sodium in the bloodstream, which in turn decreases the osmotic pressure that draws fluid into the abdominal cavity. This dietary modification is fundamental in the management of ascites.

Choice C reason: Increasing oral fluid intake is not an appropriate action for decreasing the presence of ascites in patients with cirrhosis. Excessive fluid intake can exacerbate fluid retention and worsen ascites. Instead, fluid intake may need to be restricted depending on the patient's condition and electrolyte balance.

Choice D reason: Weighing the patient daily is a useful tool for monitoring fluid status and detecting changes in ascites. However, similar to monitoring intake and output, this action does not directly decrease the presence of ascites. It serves as a means to track the effectiveness of other interventions, such as sodium restriction and medication.

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Correct Answer is A

Explanation

Choice A reason: Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments for a client in acute respiratory failure who is receiving mechanical ventilation. ABG provides essential information about the patient's oxygenation status, carbon dioxide levels, and acid-base balance. It allows healthcare providers to assess how well the lungs are oxygenating the blood and removing carbon dioxide. By analyzing the ABG results, the effectiveness of the mechanical ventilation and any necessary adjustments can be made to improve the client's respiratory status.

Choice B reason: Blood pressure monitoring is important for evaluating the overall cardiovascular status of a patient but is not the most specific assessment for determining the effectiveness of treatments in acute respiratory failure. While blood pressure can provide indirect information about cardiac output and perfusion, it does not directly reflect the patient's oxygenation and ventilation status, which are critical in the context of respiratory failure.

Choice C reason: Heart rate monitoring is useful for assessing the patient's hemodynamic status and detecting potential arrhythmias or other cardiac issues. However, it does not provide specific information about the effectiveness of treatments for acute respiratory failure. Heart rate alone cannot indicate how well the lungs are functioning or how effectively mechanical ventilation is supporting the patient's respiratory needs.

Choice D reason: Capillary refill is a simple and quick assessment of peripheral perfusion, indicating how well the blood is flowing to the extremities. While it can provide some information about the patient's circulatory status, it is not a reliable method for determining the effectiveness of treatments in acute respiratory failure. Capillary refill does not provide direct information about oxygenation, ventilation, or the overall respiratory status of the patient.

A. The client's albumin level is increased. B. The client's platelet count is normal. C. The dressing has a 2-cm area of serous drainage. D. The client's heart rate is 122 beats/min.

Correct Answer is D

Explanation

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

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A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

Correct Answer is D

Explanation

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