A nurse is planning care for a client who has long-term liver cirrhosis and a new diagnosis of abdominal ascites. Which of the following interventions should the nurse include in the plan of care to prevent complications?
Administer furosemide.
Weigh the client weekly.
Offer the client a high-sodium diet.
Administer heparin.
The Correct Answer is B
Choice A rationale:
Administering furosemide may be appropriate for managing ascites, but it is not directly related to preventing complications. Furosemide is a diuretic that helps reduce fluid retention but does not address other potential complications of liver cirrhosis.
Choice B rationale:
Weighing the client weekly is essential to monitor changes in body weight and fluid status, which is crucial in detecting worsening ascites or fluid retention. Sudden weight gain could indicate an exacerbation of ascites or other complications, warranting timely intervention.
Choice C rationale:
Offering the client a high-sodium diet is contraindicated in managing ascites. A high-sodium diet would lead to increased fluid retention and worsen the ascites, potentially exacerbating the client's condition and increasing the risk of complications.
Choice D rationale:
Administering heparin is not relevant to preventing complications in a client with liver cirrhosis and abdominal ascites. Heparin is an anticoagulant, and its use is not indicated for this particular condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should wash the client in a distal to proximal direction during a bed bath after a cerebrovascular accident (CVA) to prevent the risk of clot dislodgement. This method ensures that any potential clots or debris are moved away from the central circulation, reducing the risk of harm.
Choice B rationale:
Using a circular motion with the washcloth can increase friction and potentially irritate the skin. Clients with a history of CVA might have reduced sensation or mobility, making them susceptible to skin breakdown. Hence, avoiding circular motions is important to prevent skin damage.
Choice C rationale:
Massaging the legs after completing the bath can also pose a risk of clot dislodgement. It is essential to avoid vigorous massage on areas affected by deep vein thrombosis (DVT) to prevent complications like pulmonary embolism.
Choice D rationale:
There is no need to disconnect the IV tubing before performing the bath unless specifically indicated by the healthcare provider. In general, clients receiving continuous IV infusions can continue the infusion while maintaining proper infection control measures during the bath.
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