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 A
Explanation
Choice A rationale:
The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.
Choice B rationale:
Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.
Choice C rationale:
Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.
Choice D rationale:
Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.
Correct Answer is C
Explanation
Choice A rationale:
Cauliflower is not a good dietary choice for a client with cholelithiasis. Cholelithiasis refers to the presence of gallstones, and certain foods, including cauliflower, can exacerbate symptoms in some individuals.
Choice B rationale:
Increasing the amount of egg yolks in the diet is not advisable for a client with cholelithiasis. Egg yolks are high in cholesterol and can contribute to gallstone formation.
Choice C rationale:
This is the correct choice. Desserts like angel-food cake are a better dietary option for a client with cholelithiasis. Angel-food cake is typically low in fat and cholesterol, making it a more suitable choice for those with gallbladder issues.
Choice D rationale:
Eating choice or prime cuts of meat is not recommended for clients with cholelithiasis. These types of meat are often higher in fat, which can trigger gallbladder symptoms.
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