The nursing care plan specifies obtaining abdominal girth measurements each shift. The nurse takes the measurement, but when compared with the previous measurement, the new finding is several millimeters off. Which action by the nurse is best?
a. Document the finding in the client's chart.
b. Look to see when the client last had a dose of diuretic.
c. Ensure that the client's abdomen and flanks are marked with pen.
d. Obtain the measurement while the client sits upright.
C
Abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies flat. To ensure that measurements are taken in the same place each time, the nurse should mark the client's abdomen and flanks with pen. Findings do need to be documented, but this is not the best action when such inconsistency is noted between measurements. Use of a di-uretic might decrease ascites, but the best action remains ensuring that measurements are taken in a consistent manner.
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Abstract journals summarize articles that have appeared in other journals
A) True B) False