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
Flank pain is not typically associated with a bowel obstruction. It is more commonly associated with kidney problems.
Choice B rationale
Watery diarrhea is not typically a symptom of bowel obstruction. Bowel obstruction usually causes constipation and inability to pass gas or stool.
Choice C rationale
Fecal vomiting is a serious symptom that can occur in severe cases of bowel obstruction. It indicates a significant blockage in the digestive tract that needs immediate medical attention.
Choice D rationale
Occult blood in the stool can be a symptom of many conditions, including bowel obstruction. However, it is not the most concerning symptom in this context.

A. “Before the procedure, you’ll need to remove any dentures.”. B. “After the procedure, you may have a sore throat for which you can use warm gargles or ice.”. C. “This test will allow the doctor to see directly into your esophagus, stomach, and part of your small intestine.”. D. “After the procedure, you can have something to drink after your gag reflex returns.”.

Correct Answer is D

Explanation

Choice A rationale
While it’s true that dentures and other oral appliances should be removed before an EGD to prevent damage or loss during the procedure, this information is not the most crucial for the patient to understand.
Choice B rationale
Although a sore throat can occur after an EGD due to the passage of the endoscope, it’s not the most important information. The patient should be aware that the sore throat is temporary and can be relieved with warm gargles or ice.
Choice C rationale

This choice is accurate. An EGD allows the doctor to directly visualize the esophagus, stomach, and part of the small intestine. However, this information, while important, is not the most critical aspect for the patient to understand about the post-procedure period.
Choice D rationale
This is the correct answer. After an EGD, it’s crucial for the patient to understand that they should not eat or drink until their gag reflex has returned. This is to prevent aspiration, which can occur if the patient tries to swallow food or liquid before the gag reflex is functioning properly.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient admitted with a possible bowel obstruction. Which patient symptom should cause the nurse the most concern?

Correct Answer is C

Explanation

After a diagnostic work-up, a 56-year-old male client was diagnosed with a duodenal ulcer caused by Helicobacter pylori infection. After treatment, the client is to have an esophagogastroduodenoscopy (EGD). Which teaching should the nurse reinforce?

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?