The nurse notes that the client admitted with cirrhosis is more anxious than usual. The client has ascites and has had a poor appetite. The client states, "I can't breathe.". The nurse's most appropriate initial response is to:
1. Evaluate the respiratory status.
2. Contact the health care provider.
3. Assess the abdomen.
4. Give the client his medication.
Evaluate the respiratory status.
Rationale: Clients with ascites may have difficulty with breathing due to the size of the abdomen. Therefore, the initial response is for the nurse to evaluate the respiratory status of the client. If there is medication ordered that may assist in decreasing the ascites, the nurse may, after evaluating the respiratory status, choose to give the medication or to contact the health care provider. Assessing the abdomen will reveal ascites.
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