An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client’s plan of care?

Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.

Choice A rationale
Maintaining the prescribed fluid restriction is crucial in the management of SIADH. Fluid restriction helps to prevent further dilution of sodium in the blood, which can exacerbate the symptoms of SIADH34.
Choice B rationale
Withholding the next scheduled dose of treatment is not necessarily the appropriate intervention based on the increase in serum sodium level. The treatment plan should be adjusted based on the patient’s overall clinical picture and in consultation with the healthcare provider.
Choice C rationale
Increasing neurologic checks to every 2 hours is not directly related to the increase in serum sodium level. While neurologic checks are important in monitoring the overall health status of the patient, they are not specifically indicated based on the serum sodium level alone.
Choice D rationale
Assessing for increasing fluid volume overload is not the appropriate intervention based on the increase in serum sodium level. SIADH is characterized by water retention, not fluid volume overload.