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 D

Explanation

Choice A rationale
Chlorhexidine is an antiseptic that is used for cleaning the skin or the hands and helps to prevent infections caused by bacteria. However, it is not the recommended cleansing agent for hand hygiene in a Clostridium difficile infection.
Choice B rationale
Alcohol-based antiseptics are commonly used for hand hygiene in healthcare settings. However, they are not effective against Clostridium difficile spores.
Choice C rationale
Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It may not be effective against Clostridium difficile spores.
Choice D rationale
Soap and water are recommended for hand hygiene when caring for a patient with a Clostridium difficile infection. This is because soap and water are effective in removing C. difficile spores from hands.

A. Assure the patient the problem is temporary. B. Cut the food into small pieces. C. Report the observation to the healthcare provider (HCP). D. Offer the patient liquids instead.

Correct Answer is C

Explanation

Choice A rationale
Assuring the patient that the problem is temporary may not be accurate. Postoperative dysphagia could indicate a complication from the surgery, such as the stomach fundus being wrapped too tight around the esophagus, causing food obstruction. It’s important to not dismiss the patient’s concerns without proper assessment.
Choice B rationale
Cutting the food into small pieces might help the patient swallow easier, but it does not address the underlying issue. The patient’s difficulty in swallowing could be a sign of a serious problem that needs medical attention.
Choice C rationale
Reporting the observation to the healthcare provider (HCP) is the correct action. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction.
Choice D rationale

Offering the patient liquids instead might alleviate the symptom temporarily, but it does not solve the potential problem. The healthcare provider needs to be informed about the dysphagia to assess and treat the possible complication.

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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 nurse is caring for a patient who has a Clostridium difficile infection. Which cleansing agent should the nurse use for hand hygiene?

Correct Answer is D

Explanation

The nurse is providing care for a patient who had surgical repair of a paraesophageal (rolling) hernia. The nurse observes that the patient is having difficulty swallowing during the first postoperative meal.What action should the nurse take?

Correct Answer is C

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?