A nurse is assisting with the care of a client who has cirrhosis of the liver with ascites. Which of the following actions should the nurse take?

a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.

b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.

c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.

d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.

a. Decrease the IV fluid infusion rate and limit oral fluid intake: The client's BUN and creatinine levels are not significantly elevated, and limiting fluid intake may exacerbate dehydration.

Decreasing the IV fluid rate may not be indicated without further assessment.

b. Collect a urine specimen for culture and sensitivity: While obtaining a urine specimen is

important, the priority in this case is to evaluate the urine output for amount and specific gravity to assess renal function and fluid balance.

c. Continue routine care because the results are within the expected reference range: The elevated BUN, along with nausea and vomiting, suggests the need for further assessment rather than

continuing routine care without adjustments.

d. Evaluate urine output for amount and urine for specific gravity: This is the correct action to assess renal function and fluid balance. Monitoring urine output and specific gravity will help determine if the client's kidneys are effectively concentrating urine and adequately excreting waste products.