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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clean the peristomal skin four times a day:
While keeping the peristomal skin clean is essential, cleaning it four times a day might be excessive and could lead to skin irritation. Typically, cleansing the area when changing the pouch or as needed is sufficient.
B. Hold pressure on the skin barrier for 10 to 15 seconds to secure the seal:
Applying gentle pressure upon application can assist in securing the seal, but the duration might vary based on the manufacturer's recommendations. It's important not to overly press or manipulate the barrier excessively, as it could cause skin trauma.
C. Empty the pouch when it is 1/3 full:
This is the correct advice. Regularly emptying the pouch prevents leakage and ensures the pouch does not become too heavy or cause skin irritation from weight or pressure.
D. Expect firm fecal content:
With an ileostomy, the fecal content tends to be more liquid compared to other types of ostomies like colostomies, so expecting firm fecal content might not be accurate for this situation.
Correct Answer is C
Explanation
A. "I'll wear sandals in warm weather":
While wearing sandals in warm weather can be comfortable, it may not provide adequate protection for the feet, especially for individuals with diabetes. Closed, protective shoes are generally recommended to prevent injuries.
B. "I'll put lotion between my toes after drying my feet":
Applying lotion between the toes can create a moist environment, which may increase the risk of fungal infections. It is generally advisable to keep the skin between the toes dry to prevent infections.
C. "I'll check my feet every day for sores and bruises":
This statement is correct. Regular foot checks are crucial for individuals with diabetes to identify any signs of sores, bruises, or other abnormalities early. Early detection and prompt treatment can help prevent complications.
D. "I’ll soak my feet in cool water every night before I go to bed":
Soaking the feet in cool water is generally not recommended, as it can lead to maceration of the skin and increase the risk of fungal infections. Daily inspection and proper hygiene are more important aspects of foot care.
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