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A nurse is evaluating a client admitted to the emergency unit.

Exhibits
Which nursing interventions are appropriate for managing a patient with cirrhosis experiencing fluid volume excess?

A.

Advise strict bed rest

B.

Encourage high-sodium diet

C.

Administer diuretics as prescribed

D.

Monitor abdominal girth daily

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Rationale

  • Advise strict bed rest → Contraindicated
     Strict bed rest is not necessary unless the patient is severely compromised; mobility is encouraged to prevent complications.
     
  • Encourage high-sodium diet → Contraindicated
     A low-sodium diet is essential to reduce fluid retention and ascites; high sodium worsens edema.
     
  • Administer diuretics as prescribed → Anticipated
     Diuretics (e.g., spironolactone, furosemide) help reduce ascites and edema.
     
  • Monitor abdominal girth daily → Anticipated
     Helps track fluid accumulation and assess effectiveness of interventions.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. Epigastrium refers to the upper central region of the abdomen, just below the sternum; Cullen’s sign does not appear here.
B. Umbilical region (around the navel) is where Cullen’s sign appears as a bluish discoloration due to subcutaneous fat necrosis or retroperitoneal bleeding associated with acute pancreatitis. This is the correct site.
C. Flank discoloration is known as Grey Turner’s sign, another indicator of retroperitoneal bleeding, but distinct from Cullen’s sign.
D. Subumbilical refers to the area below the umbilicus, not the typical site for Cullen’s sign.

Correct Answer is C

Explanation

Rationale:

A. The tubing for TPN must be changed every 24 hr (not 48 hr) to reduce the risk of central line–associated bloodstream infection (CLABSI).

B. Lipid emulsions should not hang for more than 12 hr to prevent bacterial growth and infection.

C. A 1.2-micron filter is required for TPN that contains lipids to remove particulate matter, bacteria, and fungi, since lipid solutions cannot pass through smaller filters.

D. TPN solutions should be changed every 24 hr (not 36 hr) to reduce infection risk.

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