A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Encourage weight lifting during physical therapy

Measure the client's abdominal girth.

Administer warfarin.

Administer furosemide.

Implement a low-sodium diet.

Answer and Explanation

Correct Answer : B,D,E

A. Encourage weight lifting during physical therapy:

Encouraging weight lifting or strenuous physical activities might not be advisable for individuals with advanced cirrhosis. Engaging in intense physical activity could potentially strain the liver or increase the risk of injury or bleeding, which is already heightened in individuals with cirrhosis.

B. Measure the client's abdominal girth:

Monitoring the client's abdominal girth is essential because cirrhosis can lead to the accumulation of fluid in the abdomen, known as ascites. Changes in abdominal girth can indicate the progression or resolution of ascites, guiding treatment and interventions.

C. Administer warfarin:

Administering warfarin, an anticoagulant, might not be ideal in cirrhosis due to the increased risk of bleeding. Liver dysfunction in cirrhosis can impair the production of clotting factors, increasing the risk of bleeding complications.

D. Administer furosemide:

Furosemide, a diuretic, can be utilized in managing ascites by promoting the elimination of excess fluid. However, its use requires careful monitoring, considering the electrolyte balance and potential adverse effects, especially in individuals with liver impairment.

E. Implement a low-sodium diet:

A low-sodium diet is crucial in managing cirrhosis-related complications, particularly ascites and edema. Sodium restriction helps reduce fluid retention, lessening the burden on the liver and alleviating symptoms associated with fluid accumulation.

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Correct Answer is C

Explanation

A. The charge nurse should follow the staff closely and tell them every single thing they could possibly be doing wrong:

Micromanaging and focusing solely on the negatives can create a stressful and demoralizing work environment. This approach is less likely to motivate and inspire staff.

B. Make the staff aware that all errors will be severely punished:

A punitive approach to errors can create a culture of fear and may not foster a supportive environment for learning and improvement. It can lead to decreased morale and job satisfaction.

C. Acknowledge staff accomplishments when warranted and provide positive feedback:

This is the most effective approach. Recognizing and acknowledging staff achievements, providing positive feedback, and celebrating successes contribute to a positive work environment. It motivates staff to continue their efforts and fosters a culture of teamwork and collaboration.

D. Provide negative feedback with all errors:

While constructive feedback is essential for learning and improvement, a balance between constructive criticism and positive reinforcement is crucial. Constant negative feedback without recognition of positive efforts can lead to decreased morale.

A. Potassium B. Ammonia C. Glucose D. Bicarbonate

Correct Answer is B

Explanation

A. Lactulose is not used to decrease potassium levels. It is a laxative that works by drawing water into the colon, softening stools and promoting bowel movements.

B. Lactulose is used to decrease ammonia levels in clients with cirrhosis. Ammonia is a byproduct of protein metabolism, and when the liver is compromised, it may not effectively convert ammonia into urea, leading to elevated ammonia levels in the bloodstream. Lactulose helps reduce ammonia absorption in the colon.

C. Lactulose does not decrease glucose levels significantly. It is not primarily used as an antidiabetic medication.

D. Lactulose does not affect bicarbonate levels significantly. It primarily targets ammonia reduction in clients with cirrhosis.

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A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is looking to motivate the staff and to produce better outcomes on the unit. Which of the following behaviors by the charge nurse will produce those results?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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