The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. As the nurse inspected the client's abdomen, the nurse suspected that the client had developed ascites
The nurse would perform which of the following nursing interventions as a result of this finding? Standard Text: Select all that apply. 1. Obtain stool specimen for occult blood.
2. Measure the client's abdominal girth.
3. Obtain stool specimen for culture and sensitivity.
4. Bilateral leg measurements.
5. Percuss the abdomen at midline.
2,5
Rationale 1: Obtain stool specimen for occult blood. The nurse would not necessarily suspect that the client had occult blood in the stool.
Rationale 2: Measure the client's abdominal girth. When ascites is suspected, the abdominal girth should be measured to obtain a baseline for further evaluation.
Rationale 3: Obtain stool specimen for culture and sensitivity. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract.
Rationale 4: Bilateral leg measurements. The nurse does not necessarily need to measure the circumferences of the client's legs for edema.
Rationale 5: Percuss the abdomen at midline. The nurse would need to assess the client's abdomen for tympany during percussion. This is a sign of ascites.
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In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which ECG change with effectiveness of therapy?
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1. Abnormal hypoglossal nerve response 2. First cranial nerve (CN I) damage 3. Sluggish oculomotor response 4. Absence of Homans' sign
A nurse is employed by a local public health department and provides direct care services to clients in the community. Which of the following payer sources is likely to be responsible for reimbursing for this care? (Select all that apply.)
a. Legislative appropriations b. The client who uses a sliding fee scale c. Private insurance d. State health agency e. Centers for Disease Control and Prevention f. Medicare and Medicaid