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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.
Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.
Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.
Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.
Correct Answer is ["A","B","E"]
Explanation
Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.
Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.
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