A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?
(Select all that apply.)

Provide diet low in phosphorus.

Note signs of swelling and edema.

Increase oral fluid intake to 1,500 mL daily.

Monitor abdominal girth.

Report serum albumin and globulin levels.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.

Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.

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Correct Answer is B

Explanation

Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.

A. Quiet, calm surroundings. B. Stimulating sounds and activity. C. Cool, moist air. D. Frequent exposure to sunlight.

Correct Answer is D

Explanation

Choice D is correct because frequent exposure to sunlight is the most significant environmental factor when planning care for a client with osteomalacia. Osteomalacia is a condition in which the bones become soft and weak due to inadequate mineralization, often caused by vitamin D deficiency. Vitamin D is essential for calcium absorption and bone health, and it can be synthesized by the skin when exposed to sunlight. The nurse should encourage the client to get at least 15 minutes of sunlight per day or take vitamin D supplements as prescribed.

Choice A is incorrect because quiet, calm surroundings are not a specific environmental factor for a client with osteomalacia. Quiet, calm surroundings may help reduce stress and promote relaxation, but they do not affect bone mineralization or vitamin D synthesis.

Choice B is incorrect because stimulating sounds and activity are not a specific environmental factor for a client with osteomalacia. Stimulating sounds and activity may help improve mood and cognition, but they do not affect bone mineralization or vitamin D synthesis.

Choice C is incorrect because cool, moist air is not a specific environmental factor for a client with osteomalacia. Cool, moist air may help relieve respiratory symptoms or allergies, but it does not affect bone mineralization or vitamin D synthesis.

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A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?(Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is B

Explanation

Which environmental factor is most significant when planning care for a client with osteomalacia?

Correct Answer is D

Explanation

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A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement?
(Select all that apply.)