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 C
Explanation
Choice A rationale:
The nurse should not advise the client with multiple sclerosis to schedule all physical activities for the morning hours. While some individuals with multiple sclerosis may experience increased fatigue later in the day, the best approach is to encourage the client to schedule activities at times when they feel the most energetic and to balance physical activity with rest throughout the day.
Choice B rationale:
Monitoring blood pressure is essential while taking fingolimod, a medication used to treat multiple sclerosis, as it can cause a transient decrease in heart rate and blood pressure.
Therefore, the nurse should include this statement in the teaching to ensure the client's safety and early detection of any issues.
Choice C rationale:
This is the correct statement to include in the teaching. Clients with multiple sclerosis should avoid rigorous activities that increase body temperature, as this can worsen their symptoms due to the sensitivity of demyelinated nerves to heat. Activities such as hot baths or engaging in strenuous exercise in hot weather should be avoided.
Choice D rationale:
Corticosteroids are not typically used as a long-term treatment for multiple sclerosis. Instead, they are used for short courses during exacerbations to reduce inflammation and manage acute symptoms. Long-term use of corticosteroids can lead to significant adverse effects, so the nurse should not include this statement in the teaching.
Correct Answer is C
Explanation
Choice A rationale:
Leflunomide is a disease-modifying antirheumatic drug (DMARD) used for rheumatoid arthritis, but it does not typically result in decreased swelling within one week. It usually takes several weeks or even months for its full effect to be observed.
Choice B rationale:
Applying hot packs directly to the joint for pain relief is not recommended for rheumatoid arthritis, as heat can exacerbate inflammation. Cold packs or other anti-inflammatory measures are more appropriate.
Choice C rationale:
Steroid medications, such as prednisone, can lead to bone density loss and an increased risk of osteoporosis. Taking calcium and vitamin D supplements helps to mitigate this risk.
Choice D rationale:
The Varicella vaccine is not directly related to rheumatoid arthritis. It is important for immune support, but it is not specifically required for rheumatoid arthritis treatment.
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