A client with a history of chronic liver disease presents to the clinic with abdominal distension and discomfort. Physical examination reveals moderate ascites. The patient is prescribed a low-sodium diet and diuretics. Which nursing intervention is a priority for this patient?

Assess for signs of hepatic encephalopathy.

Administer a potassium supplement.

Encourage fluid restriction.

Promote ambulation and leg elevation.

Answer and Explanation

The Correct Answer is A

Ascites in chronic liver disease results from portal hypertension and decreased serum albumin levels, leading to third-spacing of fluid. While diuretics manage fluid volume, they can precipitate electrolyte imbalances that elevate systemic ammonia levels. Monitoring for cognitive changes is vital because neurotoxic accumulation leads to life-threatening hepatic encephalopathy and coma.

Rationale:

A. Assessing for signs of hepatic encephalopathy is the priority nursing intervention. Diuretic therapy and fluid shifts can trigger metabolic imbalances that cause ammonia to cross the blood-brain barrier. Early detection of confusion, asterixis, or altered sleep patterns is critical to prevent permanent neurological damage or death in patients with advanced cirrhosis.

B. Administering a potassium supplement may be inappropriate depending on the type of diuretic used. If the patient is prescribed potassium-sparing diuretics like spironolactone, supplementation could cause dangerous hyperkalemia. Electrolyte replacement must always be based on current serum laboratory values rather than being a generalized priority intervention for all patients with ascites.

C. Fluid restriction is often implemented in severe cases, but it is secondary to neuro-metabolic monitoring. While reducing fluid intake helps manage the total volume of ascites, it does not address the most acute risk of liver failure. Safety and neurological stability take precedence over the mechanical management of abdominal distension through fluid limitations alone.

D. Promoting ambulation and leg elevation may help reduce peripheral edema but does not address the underlying pathology of ascites. In fact, excessive ambulation may sometimes decrease renal blood flow in patients with severe portal hypertension. While leg elevation is helpful for venous return, it is not a priority compared to assessing for life-threatening hepatic complications.

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Correct Answer is D

Explanation

Furosemideis a potent loop diureticthat inhibits the sodium-potassium-chloride symporter in the thick ascending limb of the loop of Henle. By preventing the reabsorption of these electrolytes, it promotes osmotic diuresis, effectively reducing intravascular volume and systemic edema. In chronic kidney disease, monitoring the balance between fluid intake and excretion is vital to prevent circulatory overloadand worsening renal tension.

Rationale:

A.Palpating the abdomen is not an effective method for assessing the therapeutic response to a diuretic. While the nurse might check for ascites in advanced liver or renal failure, abdominal palpation does not provide quantifiable data regarding fluid loss. Daily weights and intake/output measurements provide the objective evidence needed to evaluate the success of pharmacological volume reduction.

B.Assessing diet history is important for managing sodium and fluid intake in renal patients, but it does not measure the actual effectiveness of furosemide. While a high-sodium diet can counteract the drug's effects, the diet history is a record of input rather than a measure of the drug's output and therapeutic impact on the patient's current fluid status.

C.Auscultating heart and breath sounds is a necessary assessment to detect complications of fluid volume excess, such as pulmonary edema or S3 gallops. However, while these findings provide a "snapshot" of current status, they are less sensitive for daily titration compared to weight. Improvements in lung sounds are secondary to the primary goal of actual fluid mass reduction.

D.Obtaining daily weightsis the most accurate and "best" action to assess the therapeutic effect of furosemide. Since 1 liter of fluid equals 1 kilogram of body mass, weight changes are the most sensitive indicator of fluid volumefluctuations. This provides the nurse and provider with objective, daily data to ensure the medication is successfully mobilizing excess extracellular fluid.

A. “When I buy meat, I ask for the leanest cut that is available." B. “I quit smoking 6 months ago." C. "Sometimes I wake up gasping for air in the middle of the night.” D. “My family likes to eat small meals every 3 to 4 hours throughout the day.”

Correct Answer is C

Explanation

GERD can lead to severe extra-esophageal complications if gastric refluxate reaches the upper airway. During sleep, the protective laryngeal reflexes are diminished, allowing for the microaspirationof acid into the trachea and lungs. This can cause laryngospasm, chronic cough, and nocturnal asthma-like symptoms. Identifying these occurrences is critical to prevent permanent pulmonary damage and to screen for Barrett's esophagus.

Rationale:

A.Reporting the use of lean cuts of meat is a positive finding that indicates the patient is following dietary recommendations to manage their GERD. Lean meats reduce the fat load in the stomach, which helps prevent delayed gastric emptying and minimizes the risk of reflux. This is a sign of effective self-management rather than an alarming finding for the provider.

B.Quitting smoking is a significant health achievement that improves GERD symptoms because nicotine is a known relaxant of the lower esophageal sphincter. This information should be documented as a positive behavioral change in the patient's history. It does not represent a new or worsening complication that requires an urgent medical report or intervention.

C.The nurse must report "waking up gasping for air" because it suggests nocturnal aspirationof gastric contents. This is a serious complication of GERD where acid enters the airway, potentially causing aspiration pneumoniaor bronchospasm. This finding indicates that the patient's GERD is not well-controlled and poses a significant risk to their respiratory health and airway patency.

D.Eating small, frequent meals is a recommended lifestyle modification for GERD. This practice prevents excessive gastric distention, which reduces the pressure against the lower esophageal sphincter and decreases the volume of acid available for reflux. This finding shows the patient is adhering to appropriate non-pharmacological management strategies and is not a cause for medical concern.

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A client with a history of chronic liver disease presents to the clinic with abdominal distension and discomfort. Physical examination reveals moderate ascites. The patient is prescribed a low-sodium diet and diuretics. Which nursing intervention is a priority for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is taking furosemide for the management of early chronic kidney disease (CKD). To assess the therapeutic effect of the medication, what action of the nurse is best?

Correct Answer is D

Explanation

The nurse is assessing a client who reports having a history of gastroesophageal reflux disease (GERD). Which assessment finding does the nurse report to the primary health care provider?

Correct Answer is C

Explanation

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