A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.

B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.

C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.

D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.

A.

A. Monitor for abdominal ascites - Ascites is a common complication of cirrhosis due to portal hypertension and decreased albumin production. Monitoring for abdominal distention and fluid

accumulation is essential for assessing the progression of cirrhosis and implementing appropriate interventions.

B. Implement a low-carbohydrate diet - While dietary modifications may be necessary for clients with cirrhosis, such as reducing sodium intake, implementing a low-carbohydrate diet is not typically a primary intervention for cirrhosis.

C. Review serum amylase levels - Serum amylase levels are typically assessed to diagnose pancreatitis, which is not directly related to cirrhosis unless complications such as alcoholic pancreatitis are present.

D. Place warm compresses on areas of pruritus - Pruritus (itching) is a common symptom of liver disease, including cirrhosis, due to bile salt accumulation. While warm compresses may provide

temporary relief, they do not address the underlying cause of pruritus in cirrhosis.