Which nursing interventions should the RN implement when providing care for a patient with ascites related to Cirrhosis of the liver? Select all that apply.

Administer furosemide as prescribed.

Encourage an increase in oral fluids.

Prepare patient for a paracentesis

Maintain strict intake and output.

Ambulate in hallway three times daily.

Answer and Explanation

The Correct Answer is ["A","C","D","E"]

A. Administer furosemide as prescribed: Furosemide promotes diuresis in patients with ascites, thereby relieving abdominal distension and associated discomfort. It is used carefully alongside electrolyte monitoring to prevent complications such as hypokalemia or dehydration.

B. Encourage an increase in oral fluids: Increasing fluid intake is generally contraindicated in patients with ascites, especially if they also have dilutional hyponatremia. Fluid restriction is more appropriate to prevent worsening of fluid retention and further strain on liver function.

C. Prepare patient for a paracentesis: Paracentesis is an effective procedure for relieving severe ascites in cirrhosis. This intervention provides symptomatic relief and can improve respiratory function and comfort in advanced cases.

D. Maintain strict intake and output: Monitoring fluid balance is critical in managing ascites. Accurate intake and output records help evaluate the effectiveness of diuretic therapy and detect complications like fluid overload or electrolyte imbalance.

E. Ambulate in hallway three times daily: While it doesn’t directly reduce ascites, mobility improves circulation, reduces the risk of venous stasis and thromboembolism, and supports overall physical function.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D","E","G","H"]

Explanation

A. Oxygen saturation of 98% on room air is within normal limits and not immediately concerning. There is no sign of respiratory distress or hypoxia that requires acute intervention.

B. Blurry vision may be a sign of acute hyperglycemia affecting ocular perfusion or swelling of the lens, often seen during diabetic ketoacidosis (DKA). Visual changes can be transient but signal metabolic instability that needs monitoring.

C. Blood pressure of 90/54 mmHg is hypotensive, which may indicate dehydration and poor perfusion, common in DKA due to osmotic diuresis. It also raises concern for shock if not treated promptly.

D. Blood glucose displaying “hi” on the glucometer indicates levels likely above 600 mg/dL, pointing toward a hyperglycemic crisis like DKA and requiring immediate insulin and fluid therapy.

E. Nausea is an early symptom of DKA as ketone accumulation and metabolic acidosis irritate the gastrointestinal system. This also increases the risk for further dehydration and electrolyte imbalances.

F. Pain level reported as 0/10 indicates the patient is currently not in discomfort. While headache was mentioned, its absence as a pain concern suggests it is not a critical issue at this moment.

G. Fruity odor to breath is a hallmark of ketone accumulation, indicating ketosis or ketoacidosis. This is a critical red flag that demands prompt insulin and hydration therapy to avoid worsening acidosis.

H. Heart rate of 122 bpm is tachycardia, a compensatory response to dehydration and hypotension in DKA. Persistent tachycardia with low BP is a sign of fluid deficit and early circulatory compromise.

A. "My period ended 2 days ago." B. "I don't eat shellfish because it gives me hives." C. "The last time I voided it was painful and red-tinged." D. "I drink at least 2 quarts of fluid every day."

Correct Answer is B

Explanation

A. "My period ended 2 days ago.” Having recently completed menstruation does not impact the safety or effectiveness of an intravenous pyelogram (IVP). This information is routine and does not require reporting unless the client is currently pregnant or suspects pregnancy, which would pose a risk due to radiation exposure.

B. "I don't eat shellfish because it gives me hives." A history of hives related to shellfish may indicate an allergy to iodine, which is commonly used in the contrast dye for IVP. This allergic reaction can potentially lead to severe anaphylaxis if the contrast is administered. The provider must be informed immediately.

C. "The last time I voided it was painful and red-tinged." These symptoms are likely related to the kidney stones and are relevant but not a contraindication for the IVP. It should be documented and addressed, but it does not require reporting before the procedure unless worsening or related to infection.

D. "I drink at least 2 quarts of fluid every day." Adequate hydration is encouraged before and after an IVP to facilitate dye excretion and prevent renal complications. This statement is favorable and supports safe preparation for the procedure, so it does not require provider notification.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which nursing interventions should the RN implement when providing care for a patient with ascites related to Cirrhosis of the liver? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with diabetes. Exhibits The nurse has just completed the on-coming shift assessment for their client. Select the "6" findings that require immediate follow-up

Correct Answer is ["B","C","D","E","G","H"]

Explanation

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

A nurse is caring for a male client who has a urinary tract infection. Which of the following conditions is the client most likely to develop as a result of the UTI?

The nurse is caring for a patient with diabetes. Exhibits Complete the following sentence by choosing from the list of options. The client is at highest risk for developing dropdown as evidence by the client's dropdown.

The nurse is assessing an adult patient with Type 1 diabetes mellitus. Which labs result should be reported to the physician immediately? Select the "3" findings that require immediate follow-up.

A patient newly diagnosed with hyperthyroidism has a fever of 101.3°F. Which additional assessment findings should the nurse identify as those associated with thyroid storm? Select all that apply.

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis?

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?