A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

Position the client flat in bed.

Weigh the client weekly.

Medicate the client with acetaminophen for discomfort.

Measure the client’s abdominal girth every 8 hours.

Answer and Explanation

The Correct Answer is D

a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.

b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.

c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.

d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.

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Correct Answer is B

Explanation

a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.

b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.

c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.

d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard

intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.

A. Inspiratory stridor B. Expiratory wheeze C. Coarse crackles D. Absence of breath sounds.

Correct Answer is D

Explanation

A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.

B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.

C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.

D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.

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A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has renal stones and a urinary catheter in place.Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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