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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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.

Choice B rationale:

Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.

Choice C rationale:

Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.

Choice D rationale:

Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.

A. Maintain affected leg elevated on several pillows. B. Instruct the client to wiggle the toes once every 4 hr. C. Use a hair dryer to promote drying of the cast. D. Apply heat to the client's cast to provide pain relief.

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.

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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 assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Correct Answer is C

Explanation

A nurse is caring for a client who had a fiberglass cast applied 30 min ago for a fractured tibia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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