A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?
(Select all that apply.)

Provide diet low in phosphorus.

Note signs of swelling and edema.

Increase oral fluid intake to 1,500 mL daily.

Monitor abdominal girth.

Report serum albumin and globulin levels.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.

Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.

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Correct Answer is C

Explanation

Choice A: Inspecting feet every month for ingrown nails, cuts, and calluses is not a statement that indicates understanding, as this is not frequent enough for a client with diabetes who may have impaired sensation and circulation in their feet. The recommended frequency is daily or at least weekly. This is an incorrect choice.

Choice B: Arranging diet schedule around three regular meals a day is not a statement that indicates understanding, as this may not be adequate for a client with diabetes who needs to balance their carbohydrate intake and blood glucose levels throughout the day. The recommended schedule is to have smaller and more frequent meals and snacks. This is another incorrect choice.

Choice C: Getting an eye examination with an ophthalmologist annually is a statement that indicates understanding, as this can help detect and prevent diabetic retinopathy, which can cause vision loss and blindness. Therefore, this is the correct choice.

Choice D: Using salt, herbs, and spices will improve the flavor of foods is not a statement that indicates understanding, as this may not be healthy for a client with diabetes who needs to limit their sodium intake and avoid potential interactions between herbs and medications. The recommended strategy is to use low-sodium seasonings and natural flavors. This is another incorrect choice.

A. Implement seizure precautions. B. Monitor serum potassium frequently. C. Ensure pump accuracy to prevent toxicity. D. Encourage the patient to ambulate every hour.

Correct Answer is C

Explanation

Choice A reason: This is incorrect because seizure precautions are not indicated for dopamine administration. Dopamine does not lower the seizure threshold or cause convulsions.

Choice B reason: This is incorrect because monitoring serum potassium frequently is not necessary for dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia.

Choice C reason: This is correct because ensuring pump accuracy to prevent toxicity is essential for dopamine administration. Dopamine is a potent vasoconstrictor that can cause tissue necrosis, gangrene, and hypertension if overdosed.

Choice D reason: Dopamine is given to hypotensive patients, meaning they may be weak, dizzy, or at risk of falls.Ambulating frequently could worsen hypotension and increase fall risk rather than help the patient. Instead, the nurse should monitor the patient’s hemodynamic status and ensure bed rest as needed until blood pressure stabilizes.

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A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?(Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?
(Select all that apply.)