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

Prealbumin is a protein that is produced by the liver and is an indicator of the body's nutritional status. A low prealbumin level can indicate malnutrition, which is common in clients with COPD. Therefore, a dietary referral can help the client meet their nutritional needs and prevent further complications.

A. Encourage the client to bathe frequently. B. Apply powder to the client's skin. C. Add moisturizing oil to the client's bath water. D. Place a humidifier in the client's room.

Correct Answer is D

Explanation

a.Frequent bathing can actually worsen dry, itchy skin as it can strip away the natural oils that help moisturize the skin. Instead, the nurse should encourage the client to limit bathing to shorter durations using lukewarm water and gentle, fragrance-free cleansers.

b.Powder may not provide significant relief for dry, itchy skin and can potentially irritate the skin further. It is best to focus on moisturizing and hydrating the skin to alleviate the symptoms.

c.While this might seem helpful, oils in the bath can create a slippery surface, posing a fall risk, especially for older adults. Additionally, oils might not provide sufficient hydration to the skin and could leave a residue that is not always beneficial.

d.Dry, itchy skin is a common concern among older adults, and it can be exacerbated by low humidity levels. Placing a humidifier in the client's room helps to increase the moisture content in the air, which can alleviate dryness and itchiness. The increased humidity can help prevent the skin from becoming overly dry and can provide relief from the symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory findings indicates a need to request a dietary referral for the client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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