Question

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 and notes ascites. Based on this data, which interventions will the nurse perform next?

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.

Answer 1

Upon noting ascites in a cirrhotic patient, the nurse should measure abdominal girth to monitor the fluid retention and may consider checking for occult blood in stool. Additional liver function tests and imaging like ultrasound may also be helpful in management.

Step-by-step explanation:

When the nurse performing an abdominal assessment on a client with cirrhosis notes ascites, the interventions that should be performed next include measuring the client's abdominal girth. Ascites is an indication of fluid retention in the abdominal cavity, which can be quantitatively monitored by measuring abdominal girth. This intervention enables the tracking of changes in the amount of ascitic fluid over time. Additionally, obtaining a stool specimen for occult blood might be appropriate, as individuals with cirrhosis may experience gastrointestinal bleeding. Further diagnostic tests such as liver function tests (LFTs) and imaging like an ultrasound or a CT scan may also be warranted based on the patient's clinical context.

Other less likely interventions based on the given options and the presence of ascites would be obtaining a stool specimen for culture and sensitivity, which might be done if an infection is suspected, and bilateral leg measurements, which could be relevant in the case of peripheral edema. Percussion of the abdomen could be performed as part of the physical examination to assess the distribution of fluid, although measuring the abdominal girth is more specific to monitoring ascites.