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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 ["A","B","J"]

Explanation

Rationale

  • Vital signs on admission and every 4 hr → establish baseline and monitor for instability.
  • NPO → prevent worsening GI distress and prepare for possible procedures.
  • Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr → correct fluid volume deficit and dehydration.

Correct Answer is B

Explanation

Rationale:
A. Right upper quadrant contains the liver and gallbladder; pain here is more typical of hepatobiliary disorders, not appendicitis.
B. Right lower quadrant is the correct location of McBurney’s point, found one-third of the distance from the anterior superior iliac spine to the umbilicus. Tenderness here is a classic sign of appendicitis.
C. Left lower quadrant pain is commonly associated with conditions like diverticulitis, not appendicitis.
D. Left upper quadrant contains the stomach, spleen, and pancreas tail; pain here suggests disorders of those organs, not appendicitis.

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