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.)
Implement a low-sodium diet.
Administer furosemide.
Administer warfarin.
Measure the client's abdominal girth.
Encourage weight lifting during physical therapy.
Correct Answer : A,B,D
Choice A rationale
Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.
Choice B rationale
Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.
Choice C rationale
Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.
Choice D rationale
Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.
Choice E rationale
Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Bubbling in the water seal chamber with exhalation indicates that air is still being removed from the pleural space, which is expected with a pneumothorax and is not a cause for immediate concern.
Choice B rationale
Eyelets not being visible indicate that the chest tube is properly placed within the pleural space, not an urgent issue.
Choice C rationale
Movement of the trachea towards the unaffected side is a sign of tension pneumothorax, which requires immediate intervention as it can compromise respiratory function.
Choice D rationale
Crepitus in the area above and surrounding the insertion site indicates subcutaneous emphysema, which can occur but does not necessitate immediate provider notification unless severe.
Correct Answer is D
Explanation
Choice A rationale
High-protein and high-carbohydrate foods are beneficial, but they do not directly address the immediate respiratory issues in ARDS.
Choice B rationale
Encouraging oral intake of fluids may not be appropriate as it can contribute to fluid overload and worsen pulmonary edema in ARDS patients.
Choice C rationale
Administering low-flow oxygen might be necessary but isn't the most crucial intervention for ARDS. High-flow oxygen or mechanical ventilation is typically required.
Choice D rationale
Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
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