A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites.
What action should the nurse take?

Weigh the patient weekly.

Position the patient flat in bed.

Measure the patient’s abdominal girth every 8 hours.

Administer acetaminophen for discomfort.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Weighing the patient weekly may not be sufficient in the case of cirrhosis with ascites. Fluid accumulation can occur rapidly, and more frequent weight checks may be necessary.
Choice B rationale
Positioning the patient flat in bed is not typically recommended for patients with ascites, as this can increase pressure on the diaphragm and make breathing more difficult.
Choice C rationale
Measuring the patient’s abdominal girth every 8 hours is a common nursing intervention for patients with ascites. It allows for monitoring of fluid accumulation in the abdomen.
Choice D rationale
While managing discomfort is important, acetaminophen should be used cautiously in patients with liver disease, as the liver is involved in drug metabolism.

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Correct Answer is C

Explanation

Choice A rationale
A high fiber diet is not typically recommended for a client diagnosed with acute gastroenteritis. High fiber foods can potentially exacerbate diarrhea and other symptoms.
Choice B rationale
While a low fat diet can be beneficial in many health conditions, it is not specifically recommended for a client diagnosed with acute gastroenteritis.
Choice C rationale
A low fiber diet is typically recommended for a client diagnosed with acute gastroenteritis. Low fiber foods are easier to digest and can help alleviate symptoms such as diarrhea.
Choice D rationale
A high carbohydrate diet is not typically recommended for a client diagnosed with acute gastroenteritis. High carbohydrate foods can potentially exacerbate diarrhea and other symptoms.

A. Remove the protective gown before exiting the patient’s room. B. Utilize an electronic thermometer to measure the client’s temperature. C. Shake bed linens before placing them in a linen bag. D. Take off the protective gown prior to removing gloves.

Correct Answer is D

Explanation

Choice A rationale
Removing the protective gown before exiting the patient’s room is a standard practice in infection control. However, it is not the most critical action when caring for a client with Clostridioides difficile under contact precautions.
Choice B rationale
Utilizing an electronic thermometer to measure the client’s temperature is a routine part of patient care and is not specific to contact precautions for Clostridioides difficile.
Choice C rationale
Shaking bed linens before placing them in a linen bag can potentially spread Clostridioides difficile spores, increasing the risk of transmission.
Choice D rationale
Taking off the protective gown prior to removing gloves is the correct sequence for doffing personal protective equipment (PPE). This sequence is important to prevent the spread of Clostridioides difficile to the healthcare provider and other patients.

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A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed with acute gastroenteritis. What diet would the nurse expect to be prescribed for the client?

Correct Answer is C

Explanation

A nurse is providing care for a client who has recently been diagnosed with Clostridium difficile and is under contact precautions. What action should the nurse take?

Correct Answer is D

Explanation

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A nurse is assisting in the care of a patient who has cirrhosis of the liver with ascites.
What action should the nurse take?