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 D

Explanation

Choice A reason:

Mild ankle edema is not uncommon in clients with fluid retention, such as ascites. While it requires monitoring, it does not indicate an immediate need for intervention.

Choice B reason:

Moderate abdominal distention is a common finding in clients with ascites and should be monitored, but it does not require immediate intervention.

Choice C reason:

Complaints of thirst and dry mouth may indicate dehydration, which should be addressed, but it does not require immediate intervention as other options.

Choice D reason:

This statement is correct. Respiratory distress and cyanosis are concerning findings in a client with ascites, as they may indicate severe pulmonary edema or other respiratory complications that require immediate intervention and medical attention.

A. Endoscopy. B. Cardiac catheterization. C. Lumbar puncture. D. Pulmonary function test.

Correct Answer is A

Explanation

Choice A reason:

This statement is correct. Endoscopy can be used to visualize the upper gastrointestinal tract and assess for potential sources of bleeding or varices in the esophagus, which can be related to ascites in clients with liver disease.

Choice B reason:

Cardiac catheterization is used to assess the heart and blood vessels and is not directly related to determining the underlying cause of ascites.

Choice C reason:

Lumbar puncture is performed to obtain cerebrospinal fluid for diagnostic purposes and is not typically used to evaluate ascites.

Choice D reason:

Pulmonary function tests are used to assess lung function and are not directly related to determining the underlying cause of ascites.

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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 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?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is reviewing the results of a client's diagnostic tests to confirm the presence of ascites. Which of the following laboratory findings is commonly associated with ascites?

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 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 cirrhosis and ascites is receiving medical treatment to manage the fluid accumulation. The client asks the nurse about lifestyle changes that may help improve the condition. Which of the following responses by the nurse is accurate?

A client with chronic alcohol abuse is at risk of developing ascites. The nurse explains that excessive alcohol consumption can contribute to ascites primarily by causing:

A client with liver cirrhosis and ascites is experiencing abdominal pain and discomfort. The nurse should recognize that this pain is primarily due to:

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?