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

Choice A reason: The statement "Headaches can occur due to the vasoconstriction effect of the medication" is incorrect. Nitroglycerin causes vasodilation, not vasoconstriction. Vasodilation increases blood flow, which can lead to headaches as a common side effect.

Choice B reason: Offering Morphine to manage the headache is not the most appropriate initial response. While Morphine can relieve pain, it's essential to educate the patient about the common side effects of Nitroglycerin and provide reassurance. Morphine use should be carefully considered and is typically reserved for more severe pain management.

Choice C reason: Notifying the physician immediately is not necessary in this scenario, as a headache is a known and common side effect of Nitroglycerin. It's more appropriate to educate the patient about the side effects and provide reassurance. Only if the headache is severe and unrelieved by other measures should the physician be notified.

Choice D reason: Explaining that the headache is a normal side effect of Nitroglycerin, which dilates blood vessels, is the most appropriate response. This helps to reassure the patient and provides an understanding of why the headache is occurring. Nitroglycerin works by dilating blood vessels to improve blood flow and reduce angina symptoms, and headaches are a common side effect due to this vasodilation.

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.