A nurse is contributing to the plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
Increase the client’s sodium intake.
Decrease the client’s fluid intake.
Increase the client’s saturated fat intake.
Decrease the client’s carbohydrate intake
The Correct Answer is B
Choice A: Increase the client’s sodium intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s sodium intake can worsen fluid retention and exacerbate ascites. The nurse should recommend limiting the client’s sodium intake to less than 2 g per day.
Choice B: Decrease the client’s fluid intake. This is an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. Ascites is a complication of cirrhosis that involves the accumulation of fluid in the peritoneal cavity. Decreasing the client’s fluid intake can help reduce fluid retention and prevent further distension of the abdomen and pressure on the diaphragm.
Choice C: Increase the client’s saturated fat intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s saturated fat intake can increase the risk of cardiovascular disease, obesity, and faty liver disease. The nurse should recommend a balanced diet that provides adequate protein, calories, vitamins, and minerals.
Choice D: Decrease the client’s carbohydrate intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Decreasing the client’s carbohydrate intake can cause ketosis, which is a metabolic state that occurs when the body uses fat as a fuel source instead of glucose.
Ketosis can cause nausea, fatigue, headache, and bad breath. The nurse should recommend a moderate carbohydrate intake that provides enough glucose for energy and prevents ketosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Peri-umbilical area. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The peri-umbilical area is the area around the navel, which is part of the skin. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Choice B: Nail beds. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
Choice C: Webbed areas of the fingers. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The webbed areas of the fingers are part of the skin that can show jaundice, but they may also be influenced by other factors such as temperature, circulation, or pressure.
Choice D: Hard palate. This is an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis, which is an inflammation of the gallbladder. Jaundice is a yellowish discoloration of the skin and mucous membranes due to elevated bilirubin levels in the blood. Bilirubin is a pigment that is produced from the breakdown of red blood cells and is normally excreted in bile. If the gallbladder or bile ducts are inflamed or obstructed, bile cannot flow into the duodenum and bilirubin accumulates in the blood and tissues. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
Correct Answer is A
Explanation
Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.
Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side effects.
Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.
Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or fluid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.
Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by fluid loss from vomiting and diarrhea. Weight loss can also reflect loss of muscle mass or fat tissue due to malnutrition or inflammation. Weight loss can affect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.
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