A client with liver cirrhosis is experiencing fluid retention and abdominal distension due to ascites. Which nursing intervention is essential to manage this complication?
Restricting fluid intake to reduce edema.
Encouraging the client to consume a high-sodium diet.
Assisting with paracentesis to drain the ascitic fluid.
Administering diuretics to promote urine output.
The Correct Answer is C
A) Restricting fluid intake is not appropriate for managing ascites in clients with liver cirrhosis. Ascites occurs due to fluid accumulation in the peritoneal cavity and is not primarily influenced by oral fluid intake.
B) Encouraging a high-sodium diet is contraindicated in clients with ascites. High sodium intake can exacerbate fluid retention and worsen ascites. Instead, clients with ascites should be on a low-sodium diet to reduce fluid accumulation.
C) In a client with liver cirrhosis experiencing fluid retention and abdominal distension due to ascites, paracentesis is an essential intervention to drain the accumulated ascitic fluid from the abdominal cavity. Paracentesis helps to relieve discomfort, improve respiratory function, and reduce intra-abdominal pressure.
D) Diuretics are used in the management of ascites to promote urine output and reduce fluid retention. However, paracentesis is a more immediate intervention for relieving discomfort and removing a large volume of ascitic fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A)Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to drain the accumulated fluid in clients with ascites. This procedure is performed to relieve abdominal pressure and discomfort, as well as to facilitate diagnostic testing on the ascitic fluid.
B) Thoracentesis is a procedure to drain fluid from the pleural cavity, which is the space surrounding the lungs. It is not used to treat ascites.
C) Pleurodesis is a procedure performed to create adhesions between the two layers of the pleura to prevent recurrent pleural effusions (fluid accumulation in the pleural cavity). It is not used to treat ascites.
D) Pericardiocentesis is a procedure to drain fluid from the pericardial sac surrounding the heart. It is not used to treat ascites.
Correct Answer is B
Explanation
A) While lactulose can be taken with meals to minimize gastrointestinal discomfort, its effectiveness is not necessarily enhanced by taking it with meals. The timing and dosage of lactulose should be based on the healthcare provider's instructions.
B) Lactulose is a medication commonly used to manage hepatic encephalopathy in clients with liver cirrhosis. It works by reducing ammonia levels in the blood by promoting the excretion of ammonia through the stool. The nurse should instruct the client to expect one to two soft bowel movements per day while on lactulose, as this indicates the medication's effectiveness in removing ammonia from the body.
C) Lactulose is not associated with fluid overload, and there is no need to limit fluid intake while taking the medication. In fact, adequate hydration is important in clients with liver cirrhosis.
D) Lactulose is not known to significantly affect blood glucose levels, and there is no specific need for the client to monitor blood glucose levels while taking this medication.
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