NCLEX-PN® ExaminationPhysiological AdaptationMedium
The nurse is caring for a client with ascites due to liver cirrhosis. The client's abdominal girth has increased by 5 cm in 24 hours, and they report increased shortness of breath. Which of the following is the most appropriate nursing intervention?
- APrepare the client for a paracentesis.
- BAdminister intravenous albumin as prescribed.
- CEncourage increased oral fluid intake.
- DAssist the client into a semi-Fowler's position.
Show answer & explanationAnswer & explanation
Correct answer: D. Assist the client into a semi-Fowler's position.
Increased abdominal girth and shortness of breath in a client with ascites indicate increased intra-abdominal pressure compressing the diaphragm, impairing respiratory function. Assisting the client into a semi-Fowler's position will help alleviate pressure on the diaphragm and improve lung expansion, thereby easing breathing.
Why the other options are wrong
- A. Paracentesis is a procedure to remove ascitic fluid, which would be indicated, but positioning is a more immediate and independent nursing action for respiratory distress.
- B. While albumin may be used to manage ascites, it's not the immediate priority for acute shortness of breath and increased abdominal girth.
- C. Clients with ascites are typically on fluid restrictions, so encouraging increased oral fluid intake would worsen fluid overload and ascites.
Ascites Respiratory Management
Ascites can cause respiratory distress due to increased intra-abdominal pressure on the diaphragm. Elevating the head of the bed (semi-Fowler's or high-Fowler's) helps improve lung expansion and ease breathing.
- Increased abdominal girth compresses diaphragm.
- Leads to shortness of breath.
- Semi-Fowler's position improves lung expansion.
- Fluid restriction and diuretics are also key.
Memory trick: Ascites Airway Aid: Position Up, Fluid Down