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

Answer and Explanation

The Correct Answer is 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.

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Correct Answer is D

Explanation

A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.

B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.

C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.

D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.

A. Provide a flexible activity schedule. B. Provide high-calorie nutritional supplements. C. Allow the client to eat meals alone in her room. D. Allow the client to choose her clothes independently.

Correct Answer is B

Explanation

A. A flexible activity schedule may increase overstimulation; structured activities with set limits are more appropriate for clients in acute mania.
B. Clients experiencing acute mania often have increased energy expenditure and may neglect meals; providing high-calorie nutritional supplements helps prevent weight loss and maintains adequate nutrition.
C. Eating alone may increase the risk of inadequate intake due to distraction or hyperactivity; supervised or structured meal times are safer.
D. Allowing unrestricted choice of clothing may lead to inappropriate or disorganized attire; guidance is needed to maintain safety and appropriate appearance.

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A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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