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 D

Explanation

A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.

B. “I have made an appointment to see my dentist next week.” - Dental care is important, and

scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.

C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.

D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement

indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.

A. Magnesium 1.9 mg. B. Chloride 99 mEq/L. C. Sodium 126 mEq/L. D. Potassium 3.6 mEq/L.

Correct Answer is C

Explanation

a. Magnesium 1.9 mg: This magnesium level is within the expected reference range (1.3-2.1 mEq/L).

b. Chloride 99 mEq/L: This chloride level is within the expected reference range (98-106 mEq/L).

c. Sodium 126 mEq/L: A sodium level of 126 mEq/L is significantly below the normal range (135-145 mEq/L), indicating hyponatremia, which can have serious consequences and requires prompt attention.

d. Potassium 3.6 mEq/L: This potassium level is within the expected reference range (3.5-5.0 mEq/L).

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