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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. "Insert the entire needle into your skin to administer medication completely."
Rationale:
A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.
B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.
C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.
D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.
Correct Answer is B
Explanation
Choice A rationale:
Increasing the intake of dairy products is not recommended for a client with irritable bowel syndrome (IBS) as dairy can exacerbate symptoms in some individuals, particularly if they are lactose intolerant.
Choice B rationale:
Drinking ten glasses of water each day is a helpful recommendation for clients with IBS. Staying hydrated can aid in digestion and help alleviate symptoms like constipation.
Choice C rationale:
Decreasing daily fiber intake to 20 grams is not advisable for IBS management. Adequate fiber intake is essential for maintaining bowel regularity and overall gut health. Instead, it is recommended to focus on soluble fiber and gradually increase fiber intake to avoid exacerbating symptoms.
Choice D rationale:
Encouraging the intake of clear carbonated fluids is not ideal for clients with IBS. Carbonated beverages can cause bloating and gas, potentially worsening symptoms in individuals with sensitive digestive systems. It is better to recommend non-carbonated, non-caffeinated fluids for hydration.
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