A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
Restrict the client's sodium intake to 3 g per day.
Position the client supine with legs elevated.
Measure the client's abdominal girth daily.
Keep the client's daily protein intake below 0.8 g/kg.
The Correct Answer is C
A. Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Incident report.
Whenever a medication error occurs, it should be documented in an incident report. The purpose of the incident report is to document the details of the event, including what happened, why it happened, and what was done to prevent it from happening again. Incident reports are not part of the client's medical record and are not used for disciplinary action. They are used for quality improvement and risk management purposes.
The nursing care plan is a document that outlines the client's nursing care needs and interventions. It is not the appropriate place to document a medication error.
The controlled substance inventory record is used to document the administration and dispensing of controlled substances. It is not the appropriate place to document a medication error.
The provider's progress notes document the provider's assessment, diagnosis, and treatment plan for the client. They are not the appropriate place to document a medication error.
Correct Answer is D
Explanation
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of the potential adverse effects of atorvastatin is myopathy, a condition characterized by muscle pain, weakness, and tenderness. In severe cases, myopathy can progress to rhabdomyolysis, a potentially life-threatening condition in which muscle breakdown products are released into the bloodstream and can cause kidney damage.
Therefore, the nurse should instruct the client to monitor for muscle pain, weakness, or tenderness and report these symptoms to the healthcare provider immediately. Hypoglycemia, palpitations, and daytime drowsiness are not commonly associated with atorvastatin use and would not require immediate reporting to the healthcare provider.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today