A nurse is assessing a client with ascites. The nurse notices that the client's abdomen is distended, and the skin over the abdomen is taut and shiny. Which intervention should the nurse prioritize based on this assessment finding?

Measure abdominal girth and document findings.

Elevate the client's legs to reduce abdominal fluid volume.

Administer diuretics to promote urine output and fluid removal.

Apply an abdominal binder to support the distended abdomen.

Answer and Explanation

The Correct Answer is A

Choice A reason:

This statement is correct. Measuring abdominal girth and documenting findings are essential to monitor changes in fluid accumulation and assess the effectiveness of interventions.

Choice B reason:

Elevating the client's legs may help with edema in the lower extremities but will not directly address the fluid accumulation in the abdominal cavity.

Choice C reason:

Administering diuretics may be part of the management plan for ascites, but it may not be the initial intervention to address the client's current condition.

Choice D reason:

Applying an abdominal binder may be beneficial in certain cases, but it will not directly address the underlying cause of ascites or reduce fluid accumulation in the abdomen.

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Correct Answer is A

Explanation

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.

A. Monitoring the client's blood pressure for potential hypotension. B. Administering an analgesic before the procedure to reduce pain. C. Restricting the client's fluid intake before the procedure. D. Instructing the client to maintain a supine position during the procedure.

Correct Answer is B

Explanation

Choice A reason:

Monitoring the client's blood pressure during the procedure is essential, but the nurse should prioritize administering an analgesic before the paracentesis to reduce pain and ensure the client's comfort during the procedure.

Choice B reason:

This statement is correct. Administering an analgesic before the procedure can help reduce pain and discomfort associated with paracentesis.

Choice C reason:

Restricting the client's fluid intake before the procedure is not necessary, as paracentesis is typically performed to remove fluid from the abdominal cavity and provide relief for the client.

Choice D reason:

Maintaining a supine position during the procedure is not required. The nurse should position the client comfortably, which may include elevating the head of the bed or placing the client in a side-lying position to facilitate fluid drainage.

QUESTION

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A nurse is assessing a client with ascites. The nurse notices that the client's abdomen is distended, and the skin over the abdomen is taut and shiny. Which intervention should the nurse prioritize based on this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A client with ascites is receiving paracentesis for therapeutic relief. Which action should the nurse prioritize during the procedure to ensure the client's safety and comfort?

Correct Answer is B

Explanation

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 nurse is caring for a client with suspected ascites. In addition to imaging tests, which of the following diagnostic procedures can help determine the underlying cause of the ascites?

A nurse is educating a client with cirrhosis about measures to prevent ascites exacerbation. Which of the following instructions should the nurse include in the teaching?

A client with chronic kidney disease (CKD) is at risk of developing ascites due to impaired fluid regulation. The nurse explains that the kidneys' primary function related to fluid balance is:

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

A client with cirrhosis is undergoing diagnostic tests to assess the severity and extent of ascites. The nurse explains that an imaging test commonly used to evaluate the liver and abdominal organs in this client is:

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?