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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. Replacing lost blood components requires blood products, not isotonic crystalloids.
B. Isotonic crystalloid fluids (e.g., 0.9% sodium chloride, lactated Ringer’s) are administered to restore extracellular fluid volume in clients with fluid volume deficit.
C. While isotonic solutions contain electrolytes, their primary purpose is volume replacement, not rapid electrolyte correction.
D. Correcting metabolic acidosis may require specific interventions; isotonic fluids alone do not address acid-base imbalances.

Correct Answer is C

Explanation

Rationale:
A. An obstruction of the common bile duct causes dark amber or tea-colored urine due to increased bilirubin excretion.

B. The gallbladder and common bile duct are located in the right upper quadrant, so pain is typically felt there.

C. Obstruction of the common bile duct prevents bile from reaching the intestines, impairing fat digestion and absorption, leading to steatorrhea (fatty, foul-smelling stools).

D. Ecchymosis is not a typical sign of common bile duct obstruction. It may indicate coagulation disorders, but it is unrelated to chronic cholecystitis.

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