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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["300"]
Explanation
Step 1: Determine the total time for the infusion in hours. The infusion started at 0330 and should end by 0600. So, the total time for the infusion is 0600 - 0330 = 2.5 hours.
Step 2: Calculate the total volume of IV fluid that should infuse by 0600. The IV fluids are infusing at 120 mL/hr. So, the total volume of IV fluid that should infuse by 0600 is 120 mL/hr
× 2.5 hr = 300 mL. .
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