A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Monitor for abdominal ascites.

Implement a low-carbohydrate diet.

Review serum amylase levels.

Place warm compresses on areas of pruritus

Answer and Explanation

The Correct Answer is A

A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid

accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.

B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.

C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.

D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide

temporary relief, they do not address the underlying cause of pruritus in cirrhosis.

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Correct Answer is D

Explanation

A. Taking pancrelipase on an empty stomach may not provide optimal effectiveness as there would be no food in the stomach to mix with the enzymes for proper digestion.

B. Taking pancrelipase 1 hour before meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.

C. Taking pancrelipase 1 hour after meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.

D. Taking pancrelipase with meals is the correct instruction. Pancrelipase supplements the digestive enzymes that are deficient in individuals with cystic fibrosis, helping them digest food properly. Taking it with meals ensures that the enzymes are present when food enters the stomach, optimizing digestion and nutrient absorption.

A. Set up the sterile field 7.6 cm (3 in) below waist level. B. Hold the bottle of sterile solution with the palm over the label while pouring. C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border. D. Place the lid of a bottle of sterile solution within the sterile field.

Correct Answer is C

Explanation

A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.

B. Hold the bottle of sterile solution with the palm over the label while pouring - This is

incorrect because it increases the risk of contaminating the solution by touching the label.

C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.

D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.

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A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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