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:
Wearing gloves when changing the cat's litter box is essential during chemotherapy because some chemotherapy drugs can be excreted in bodily fluids, including feces. Protecting against direct contact with potentially harmful substances is crucial to minimize exposure risks.
Choice B rationale:
Taking the temperature once each week is not a relevant precaution during chemotherapy. Monitoring temperature is important, but it should be done more frequently, such as daily, as chemotherapy can cause immunosuppression, increasing the risk of infection.
Choice C rationale:
Being able to attend a concert is not related to precautions during chemotherapy. It is essential for clients undergoing chemotherapy to avoid large gatherings and events where they might be exposed to infections.
Choice D rationale:
Allowing the toothbrush to dry completely between each use is a good hygiene practice but not specifically related to chemotherapy precautions. Proper oral hygiene is essential during chemotherapy, but using a soft toothbrush and regularly replacing it are more relevant considerations.
Correct Answer is C
Explanation
Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to addressing the client's dry mouth caused by benztropine. High-fiber foods are commonly recommended for managing constipation, a symptom often associated with Parkinson's disease, but it does not address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can stimulate saliva production and help alleviate dry mouth. However, it is not the most appropriate recommendation for a client taking benztropine, as gum-chewing may interfere with the effectiveness of the medication or exacerbate other symptoms.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the most suitable recommendation for a client experiencing dry mouth due to benztropine. Lemon-glycerin swabs can help increase saliva production and provide relief from the discomfort of dry mouth without interfering with the medication's efficacy.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat fungal infections in the mouth (oral thrush) and is not relevant to address the side effect of dry mouth caused by benztropine.
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