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. Storing unopened bottles of insulin in the freezer is incorrect. Insulin should be stored in the refrigerator, and freezing can damage the insulin.

B. Having a morning blood glucose level between 200 and 230 is too high. The target range for fasting blood glucose is generally lower, and elevated levels may indicate the need for adjustment in insulin or other medications.

C. Eating a snack half an hour before playing soccer is a correct understanding. This helps prevent hypoglycemia during physical activity. Physical activity can lower blood glucose levels, and a pre-activity snack can provide additional carbohydrates to prevent low blood sugar.

D. Not taking regular insulin when sick is incorrect. In fact, insulin needs may increase during illness, and it is usually recommended to continue taking insulin even when sick. Adjustments to the insulin regimen may be needed under the guidance of healthcare providers.

A. Bear down. B. Exhale slowly. C. Contract the pelvic muscles. D. Take a sip of water.

Correct Answer is A

Explanation

Correct answer: A

A. Bear down:

Bear down: Asking the clientto bear down gently (as if to void) helps to expose urethral meatus.Bearing down simulates the act of urination and helps open the urethra.

B. Exhale slowly:

While exhaling slowly might help the client relax, it does not specifically assist with the insertion of the catheter as effectively as bearing down.

C. Contract the pelvic muscles:

Contracting the pelvic muscles (such as squeezing or tightening) might make catheter insertion more challenging by tensing the area where the catheter needs to pass through.

D. Take a sip of water:

Drinking water is not typically instructed during urinary catheter insertion, as it's unrelated to the process and might increase discomfort.

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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

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