The nurse assesses a client with cirrhosis who is prescribed diuretics for ascites. Which assessment findings are most important for the nurse to evaluate related to diuretic therapy? Select all that apply.

Renal function tests.

Body image disturbances.

Gastrointestinal bleeding

Electrolyte laboratory results.

increased clotting tendencies.

Answer and Explanation

Correct Answer : A,D

Rationale:

A. Renal function tests are essential to monitor in a client with cirrhosis receiving diuretics (such as spironolactone or furosemide). Diuretics increase urine output and can reduce circulating volume, potentially leading to dehydration and renal impairment. Clients with cirrhosis are already at risk for hepatorenal syndrome. Monitoring BUN and creatinine helps detect worsening kidney function early and prevents serious complications. This is directly related to diuretic therapy and is a priority.

B. Body image disturbances may occur due to ascites and abdominal distention, but this is a psychosocial concern related to the disease process itself—not a direct effect of diuretic therapy. While important for holistic care, it is not a priority assessment specific to medication safety.

C. Gastrointestinal bleeding is a serious complication of cirrhosis (often due to varices), but it is not directly caused by diuretic therapy. Monitoring for GI bleeding is important in cirrhosis overall; however, it is not specifically related to evaluating the effects or safety of diuretics.

D. Electrolyte laboratory results are critically important when a client is taking diuretics. Diuretics can cause significant electrolyte imbalances such as hypokalemia (with loop diuretics) or hyperkalemia (with potassium-sparing diuretics like spironolactone). Sodium levels may also decrease. Electrolyte disturbances can lead to cardiac dysrhythmias and neurological changes, making this a priority safety concern.

E. Increased clotting tendencies are not expected in cirrhosis; in fact, clients with cirrhosis are more likely to have decreased clotting due to reduced production of clotting factors by the liver. This finding is unrelated to diuretic therapy and is not a priority assessment in this context.

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Correct Answer is C

Explanation

Rationale:

A. While pleural effusion can occur in acute pancreatitis due to inflammation and fluid shifts, it typically presents with respiratory symptoms such as shortness of breath or decreased breath sounds. It does not directly cause a board-like abdomen, severe guarding, or absent bowel sounds.

B. Bowel obstruction can cause abdominal distention and absent bowel sounds, but it usually presents with colicky pain, vomiting, and sometimes constipation. A rigid, board-like abdomen and severe guarding suggest a more acute and dangerous intra-abdominal process.

C. A board-like abdomen, severe guarding, and absent bowel sounds are classic signs of peritonitis, which may result from a pancreatic abscess or rupture. This is a life-threatening complication of acute pancreatitis that requires immediate attention, often surgical intervention. The nurse should recognize these signs as an emergency.

D. Paralytic ileus can cause absent bowel sounds and abdominal distention, but it usually does not cause severe localized tenderness or a rigid, board-like abdomen. It is serious but less immediately life-threatening than peritonitis from a pancreatic abscess.

A. Three-way Foley with warmed lavage fluid B. Bag-valve-mask with warmed humidified oxygen C. Cardiopulmonary bypass machine D. Several warm blankets and warming pads.

Correct Answer is D

Explanation

Rationale:

A. This method (bladder or gastric lavage with warmed fluids) is considered a core rewarming technique, but it is invasive and typically reserved for unconscious or severely unstable clients. It is not the first choice for a conscious client who can still regulate airway and tolerate noninvasive warming.

B. While warmed, humidified oxygen can help raise body temperature, the bag-valve-mask is primarily for respiratory support in clients who are not breathing adequately. A conscious client with stable breathing usually does not need this equipment.

C. This is an invasive, high-risk method used only in extreme hypothermia with cardiac instability or failure. It is not appropriate for a conscious client who can be managed with less invasive methods.

D. For a conscious client with severe hypothermia, external warming methods such as warm blankets, heating pads, or forced-air warming devices are the safest and most effective first-line interventions. They allow gradual, controlled warming while maintaining comfort and safety, and they reduce the risk of complications such as arrhythmias that can occur with rapid core warming.

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The nurse assesses a client with cirrhosis who is prescribed diuretics for ascites. Which assessment findings are most important for the nurse to evaluate related to diuretic therapy? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with acute pancreatitis presents with a board-like abdomen, guarding and absent bowel sounds. What should the nurse be most concerned about?

Correct Answer is C

Explanation

The health care provider prescribes core warming methods for a conscious client with severe hypothermia. What equipment should the nurse obtain?

Correct Answer is D

Explanation

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