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
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Not all clients with a history of MRSA will require antibiotics. Treatment depends on the presence of active infection, colonization, and other clinical factors.
B. There is no evidence to suggest that individuals can develop immunity to MRSA. MRSA remains a significant pathogen, and individuals with a history of MRSA remain susceptible to reinfection or colonization.
C. A protective environment is not typically required for clients with a history of MRSA. Standard precautions, including hand hygiene and appropriate use of personal protective equipment, are sufficient to prevent transmission.
D. Clients with a history of MRSA can still carry the bacteria on their skin or in their nasal passages and may transmit the infection to others, especially in healthcare settings. Therefore, it is important to adhere to infection control practices to prevent transmission.
Correct Answer is B
Explanation
A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.
B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.
C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.
D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.
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