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 A

Explanation

Choice A rationale
A clear liquid diet may not provide adequate nutrition for a patient with peritonitis. Peritonitis, an inflammation of the peritoneum, can be caused by infection, including from bacteria or fungi, or by a rupture in the abdomen. It’s a serious condition that requires immediate treatment, often including antibiotics and surgery.
Choice B rationale
Nasogastric tube insertion can be a part of the management for peritonitis. It can help decompress the stomach and relieve symptoms such as nausea and vomiting.
Choice C rationale
Intravenous antibiotics are typically a part of the treatment plan for peritonitis, as the condition is often caused by an infection.
Choice D rationale
Strict intake and output monitoring is important in the management of peritonitis. It helps assess the patient’s fluid balance and response to treatment.

A. Expect the patient to express his pain both verbally and nonverbally B. Administer opioids with caution because they will eventually lead to addiction C. Consider the patient’s individual expression of pain D. Use a scale from 0 to 10 to monitor the severity of the patient’s pain

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.

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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

The nurse is reviewing the medical record of a patient with peritonitis. Which prescription should prompt the nurse to seek clarification from the gastroenterologist?

Correct Answer is A

Explanation

A nurse is caring for a postoperative patient. When helping to manage the patient’s pain, which of the following principles should the nurse apply? (Select all that apply)

Correct Answer is ["A","C","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?