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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.

None

Answer and Explanation

The Correct Answer is A

Answer: A. Administer furosemide.

Rationales

A. Administer furosemide.
Furosemide, a loop diuretic, helps reduce fluid overload by promoting urinary excretion of sodium and water. In a client with cirrhosis and ascites, it decreases abdominal distention, eases breathing by reducing pressure on the diaphragm, and prevents complications related to severe fluid accumulation.

B. Weigh the client weekly.
Weekly weights would not provide sufficient monitoring for a client with ascites, since fluid retention can change rapidly within hours or days. Daily weights are necessary to detect subtle increases in fluid status and to evaluate the effectiveness of treatment.

C. Offer the client a high-sodium diet.
A high-sodium diet would worsen fluid retention and ascites, as sodium promotes water retention. Instead, a low-sodium diet is indicated to limit further fluid buildup in the peritoneal cavity.

D. Administer heparin.
Heparin is not a standard intervention for cirrhosis with ascites. Because the diseased liver produces fewer clotting factors, clients are already at risk for bleeding, and anticoagulant therapy would heighten this risk without addressing the underlying problem of fluid accumulation.

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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.

A. Provide pin care when the client is 4 hours postoperative. B. Remove the weights from the traction while repositioning the client in bed. C. Assess the client's circulation every 4 hours. D. Request the client to perform ankle exercises on the affected extremity.

Correct Answer is C

Explanation

Choice A rationale:

Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.

Choice B rationale:

Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.

Choice C rationale:

Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.

Choice D rationale:

Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.

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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?

Answer: A. Administer furosemide.

Rationales

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the ABGs of a client who has pneumonia. The nurse should identify which of the following findings is an indication of respiratory acidosis.

Correct Answer is D

Explanation

A nurse is caring for a client who has a fractured hip and was placed in skeletal traction 2 hours ago. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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