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.

Answer and Explanation

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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Correct Answer is A

Explanation

The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.

Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.

Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.

It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.

A. Wash hands with soap and water for 20 seconds. B. Artificial nails can be worn when performing direct client care. C. Wear sterile gloves when in contact with body fluids. D. Use alcohol-based cleanser when hands are visibly soiled.

Correct Answer is A

Explanation

Wash hands with soap and water for 20 seconds: Washing hands with soap and water is the preferred method for hand hygiene in most situations, especially when hands are visibly soiled or contaminated with body fluids. The CDC recommends washing hands for at least 20 seconds, ensuring that all surfaces of the hands, including the back of the hands, between the fingers, and under the nails, are thoroughly cleaned.

Artificial nails should not be worn when performing direct client care: Artificial nails, including nail extensions and overlays, should be avoided when providing direct client care. The wearing of

artificial nails can increase the risk of bacterial colonization and make proper hand hygiene more challenging. Short, natural nails without nail polish are recommended for healthcare workers to ensure effective hand hygiene and reduce the risk of infection transmission.

Wear sterile gloves when in contact with body fluids: Sterile gloves are indicated when there is a need for an aseptic technique or when in contact with sterile body sites or invasive procedures.

However, for routine patient care and non-sterile procedures, non-sterile disposable gloves are typically sufficient. The use of gloves does not replace the need for proper hand hygiene before and after glove use.

Use alcohol-based cleanser when hands are visibly soiled: Alcohol-based hand sanitizers are effective in killing many types of germs when used correctly. However, they are not as effective when hands are visibly soiled or contaminated with body fluids. In such cases, washing hands with soap and water is recommended to ensure proper cleansing and removal of visible dirt or contaminants.

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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?

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