A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?
Monitor for abdominal ascites.
Implement a low-carbohydrate diet.
Review serum amylase levels.
Place warm compresses on areas of pruritus
The Correct Answer is A
A. Monitor for abdominal ascites: Clients with cirrhosis are at risk for fluid accumulation in the peritoneal cavity due to portal hypertension and hypoalbuminemia. Monitoring abdominal girth, weight, and signs of fluid retention is essential for early detection and timely intervention to prevent complications such as respiratory compromise or infection.
B. Implement a low-carbohydrate diet: Cirrhosis does not typically require a low-carbohydrate diet; instead, clients often need adequate calories and protein to prevent malnutrition. Restricting carbohydrates unnecessarily can worsen energy deficits and muscle wasting.
C. Review serum amylase levels: Serum amylase is primarily used to assess pancreatic function, not liver function. Liver disease monitoring focuses on liver enzymes (AST, ALT), bilirubin, and coagulation studies rather than amylase levels.
D. Place warm compresses on areas of pruritus: Pruritus in cirrhosis is better managed with cool baths, moisturizing creams, or medications like cholestyramine. Warm compresses can exacerbate itching by increasing skin blood flow and should generally be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry: Teaching and guiding a client on incentive spirometry is a nursing intervention that requires assessment, education, and evaluation. It cannot be delegated to assistive personnel.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort: Chest discomfort in a post-MI client is a high-priority, potentially life-threatening issue. Only a licensed nurse can assess, intervene, and notify the provider, so this task is not appropriate for delegation.
C. A client who had a stroke 2 days ago and needs help toileting: Assisting a client with toileting is a basic activity of daily living and falls within the scope of practice for assistive personnel. The nurse can delegate this task safely.
D. A client who has awoken following a bronchoscopy and requests a drink: Post-procedure assessment and evaluating readiness for oral intake requires nursing judgment to ensure airway safety. This cannot be delegated to assistive personnel.
Correct Answer is A
Explanation
A. Shellfish allergy: Glucosamine supplements are often derived from shellfish. Clients with a shellfish allergy may experience an allergic reaction if they take glucosamine, making this an important contraindication to assess before recommending the supplement.
B. History of smoking: Smoking does not directly contraindicate glucosamine use. While smoking has other health risks, it does not increase the risk of adverse effects from this supplement.
C. Cardiac dysrhythmia: Glucosamine is not known to cause cardiac dysrhythmias, and a history of dysrhythmias is generally not a contraindication. Standard monitoring is sufficient.
D. Family history of malignant hyperthermia: Malignant hyperthermia is triggered by certain anesthetic agents, not dietary supplements like glucosamine. This family history does not affect the safety of glucosamine intake.
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