Which interventions would the nurse expect in the treatment plan for a patient who is admitted to the hospital with ascites? (Select all that apply.)

Monitor fluid and electrolytes.

Provide a high-sodium diet.

Anticipate paracentesis.

Encourage high-fluid intake.

Administer an albumin infusion.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale
Monitoring fluid and electrolytes is essential in managing ascites to prevent complications such as fluid overload or electrolyte imbalances, which can exacerbate the condition.

Choice B rationale
Providing a high-sodium diet is not recommended for patients with ascites. Sodium restriction is typically advised to help manage fluid retention.

Choice C rationale
Anticipating paracentesis is appropriate as it is a procedure used to remove excess fluid from the abdominal cavity, providing relief from discomfort and respiratory difficulty.

Choice D rationale
Encouraging high-fluid intake is not recommended for ascites management. Fluid restriction may be necessary to prevent further accumulation of fluid in the abdominal cavity.

Choice E rationale
Administering an albumin infusion can be part of the treatment for ascites, especially following paracentesis, to help maintain blood volume and pressure.

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Correct Answer is C

Explanation

Choice A rationale
Monitoring calcium levels is important after administering calcium gluconate IV, but it is not the primary indicator of the medication's effectiveness in treating hyperkalemia. Calcium gluconate is used in hyperkalemia to stabilize the heart muscle, not to correct calcium levels.

Choice B rationale
Neurologic status may be affected by hyperkalemia, but changes in neurologic status are not the most direct measure of calcium gluconate's effectiveness. The medication's primary role is to address cardiac risks associated with high potassium levels.

Choice C rationale
Cardiac rhythm is the most critical aspect to monitor after administering calcium gluconate for hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and calcium gluconate works by stabilizing the cardiac membrane, thus the effectiveness of the treatment is directly reflected in the stabilization of the cardiac rhythm.

Choice D rationale
While urine volume can indicate kidney function and might indirectly reflect changes in potassium levels, it is not the direct measure of calcium gluconate's effectiveness in the emergency treatment of hyperkalemia.

A. Percuss between the iliac crest and ribs at the midaxillary line. B. Push fingers upward into the two lowest intercostal spaces. C. Palpate along both sides of the lumbar vertebral column. D. Strike a flat hand covering the costovertebral angle (CVA).

Correct Answer is D

Explanation

Choice A rationale
Percussion between the iliac crest and ribs at the midaxillary line is not the standard method for assessing flank tenderness associated with pyelonephritis. This technique may not elicit the characteristic pain of kidney inflammation.

Choice B rationale
Pushing fingers upward into the two lowest intercostal spaces is not a specific test for flank tenderness and may not accurately assess for pyelonephritis. This action is more related to assessing the integrity of the rib cage and intercostal muscles.

Choice C rationale
Palpating along both sides of the lumbar vertebral column is not the correct method for assessing flank tenderness due to pyelonephritis. This approach is more suited for assessing the musculoskeletal structure rather than the kidneys.

Choice D rationale
Striking a flat hand over the costovertebral angle is the correct method for assessing flank tenderness in cases of suspected pyelonephritis. This technique, known as costovertebral angle tenderness, elicits pain when the kidneys are inflamed, which is a common sign of pyelonephritis.

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Which interventions would the nurse expect in the treatment plan for a patient who is admitted to the hospital with ascites? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the acute glomerulonephritis prescribed calcium gluconate IV?

Correct Answer is C

Explanation

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?

Correct Answer is D

Explanation

A nurse is admitting a client who has pyelonephritis. Which of the following manifestations should the nurse expect to be present during the assessment? (Select all that apply.)

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