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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 C

Explanation

Rationale:
A. 59% dextrose in lactated Ringer’s is not a standard solution and would be hypertonic and unsafe.
B. 0.45% sodium chloride does not provide the glucose necessary to prevent hypoglycemia.
C. 10% dextrose in water (D10W) is correct. If TPN runs out, a dextrose-containing solution should be administered to prevent hypoglycemia until the next TPN bag is available.
D. Lactated Ringer’s does not provide sufficient glucose to maintain blood sugar during TPN interruption.

Correct Answer is B

Explanation

Rationale:
A. High-fiber foods are beneficial for bowel regularity and should not be decreased.
B. Excessive or chronic use of stimulant laxatives like bisacodyl can lead to electrolyte imbalances, dehydration, and dependence.
C. While rectal irritation is possible, electrolyte imbalance is the more significant risk.
D. Irregular bowel movements are common and not necessarily indicative of poor intestinal health.

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