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 A

Explanation

The correct answer is A:

Choice A reason: Review the need for the UAP to wear a face mask while in close contact with the client. Influenza is a respiratory virus that spreads mainly by droplets made when people with flu cough, sneeze or talk.A face mask can help block the spread of these droplets.

Choice B reason:Reminding the UAP to apply a fitted respirator mask before entering the client’s room is not necessary for standard influenza precautions.Respirator masks are more commonly used for airborne precautions, such as tuberculosis or measles, not for influenza.

Choice C reason:Assigning the UAP to provide care for another client and assuming full care of the client is not indicated unless the UAP is not following proper infection control procedures.There is no evidence of that in the scenario provided.

Choice D reason:Instructing the UAP to notify the nurse of any changes in the client’s respiratory status is important, but it is not the immediate action related to infection control.The priority is to prevent the spread of infection.

A. Client’s healthcare power of attorney. B. Currently prescribed medications. C. Fall at home as reason for admission. D. Increasing confusion of the client.

Correct Answer is D

Explanation

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

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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.)

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Explanation

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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.)

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.)