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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.
The correct technique for using a metered-dose inhaler does not involve tilting the head forward.
Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.
The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.
It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.
Correct Answer is A
Explanation
The client should choose a clean, dry, hairless area of skin to apply the patch. It is important to rotate the application site to avoid skin irritation and ensure consistent drug absorption. The patch should be replaced every 24 hours, not every 12 hours. If the client experiences a headache, it is not necessary to remove the patch, as headaches can be a common side effect of nitroglycerin use. Applying the patch in the same place every day can lead to skin irritation and decreased absorption.
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