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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.

Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inﬂamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.

Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.

Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.

A. Implement neutropenia isolation. B. Use alcohol hand sanitizer following client care. C. Monitor the client for manifestations of ﬂuid overload. D. Disinfect equipment with bleach solution

Correct Answer is D

Explanation

Choice A: Implement neutropenia isolation. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Neutropenia isolation is a type of protective isolation that is used for

clients who have low white blood cell counts and are at risk of infection from others. It is not indicated for clients who have Clostridium difficile infection, which is not transmited through the air.

Choice B: Use alcohol hand sanitizer following client care. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Alcohol hand sanitizer is ineﬀective against Clostridium difficile spores and can increase the risk of transmission. The nurse should wash their hands with soap and water, which can remove the spores from the skin.

Choice C: Monitor the client for manifestations of ﬂuid overload. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Fluid overload is a condition that occurs when the body retains excess ﬂuid and causes symptoms such as edema, dyspnea, and hypertension. It is not related to Clostridium difficile infection, which can cause ﬂuid loss due to diarrhea and dehydration. The nurse should monitor the client for manifestations of ﬂuid deficit, such as dry mucous membranes, tachycardia, and hypotension.

Choice D: Disinfect equipment with bleach solution. This is an action that the nurse should take for a client who has developed a Clostridium difficile infection, which is a bacterial infection that causes severe diarrhea and inﬂammation of the colon. Clostridium difficile spores are resistant to most disinfectants and can survive on surfaces for a long time. The nurse should disinfect equipment with bleach solution, which can kill the spores and prevent transmission.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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