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. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures
the time it takes for blood to clot.
b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.
c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.
d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.
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.
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