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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.
b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia
c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.
d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.
Correct Answer is B
Explanation
a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.
b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal
function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.
c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.
d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.
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