Which interventions would the nurse expect in the treatment plan for a patient who is admitted to the hospital with ascites? (Select all that apply.)
Monitor fluid and electrolytes.
Provide a high-sodium diet.
Anticipate paracentesis.
Encourage high-fluid intake.
Administer an albumin infusion.
Correct Answer : A,C,E
Choice A rationale
Monitoring fluid and electrolytes is essential in managing ascites to prevent complications such as fluid overload or electrolyte imbalances, which can exacerbate the condition.
Choice B rationale
Providing a high-sodium diet is not recommended for patients with ascites. Sodium restriction is typically advised to help manage fluid retention.
Choice C rationale
Anticipating paracentesis is appropriate as it is a procedure used to remove excess fluid from the abdominal cavity, providing relief from discomfort and respiratory difficulty.
Choice D rationale
Encouraging high-fluid intake is not recommended for ascites management. Fluid restriction may be necessary to prevent further accumulation of fluid in the abdominal cavity.
Choice E rationale
Administering an albumin infusion can be part of the treatment for ascites, especially following paracentesis, to help maintain blood volume and pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
Choice A rationale
Restricting airplane travel is not typically necessary for patients on hemodialysis unless there are specific medical concerns or complications related to their condition.
Choice B rationale
Driving restrictions are not a standard restriction for patients with end-stage kidney disease unless there are other underlying conditions that impair the ability to drive safely.
Choice C rationale
Time constraints are a significant factor for patients on hemodialysis due to the frequent and lengthy treatment sessions, which can limit their availability for other activities.
Choice D rationale
Limiting social activities to twice a week is not a standard recommendation; social interactions are important for mental health and should be encouraged as much as the patient's health allows.
Choice E rationale
Restricting foods high in potassium, sodium, and phosphorus is crucial for patients with end-stage kidney disease to help manage electrolyte levels and prevent complications.
Choice F rationale
Restricting fluid intake is essential for patients on hemodialysis to prevent fluid overload, which can lead to heart failure and other serious health issues.
Correct Answer is C
Explanation
Choice A rationale
Monitoring calcium levels is important after administering calcium gluconate IV, but it is not the primary indicator of the medication's effectiveness in treating hyperkalemia. Calcium gluconate is used in hyperkalemia to stabilize the heart muscle, not to correct calcium levels.
Choice B rationale
Neurologic status may be affected by hyperkalemia, but changes in neurologic status are not the most direct measure of calcium gluconate's effectiveness. The medication's primary role is to address cardiac risks associated with high potassium levels.
Choice C rationale
Cardiac rhythm is the most critical aspect to monitor after administering calcium gluconate for hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and calcium gluconate works by stabilizing the cardiac membrane, thus the effectiveness of the treatment is directly reflected in the stabilization of the cardiac rhythm.
Choice D rationale
While urine volume can indicate kidney function and might indirectly reflect changes in potassium levels, it is not the direct measure of calcium gluconate's effectiveness in the emergency treatment of hyperkalemia.
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