A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
Restrict the client's sodium intake to 3 g per day.
Position the client supine with legs elevated.
Measure the client's abdominal girth daily.
Keep the client's daily protein intake below 0.8 g/kg.
The Correct Answer is C
A. Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When collecting a stool specimen to check for occult blood, it is important to avoid certain foods that can affect the test results, such as red meat. Red meat can cause false-positive results due to the presence of heme, which can mimic the appearance of blood in the stool.
By avoiding red meat for at least three days before the test, the client can help ensure more accurate results. pasteurized dairy products do not have a direct impact on stool occult blood test results. However, it is important to note that certain medications, such as bismuth subsalicylate (found in Pepto-Bismol), can affect the test results.
The presence of urine in the stool sample can potentially dilute or mask the presence of blood, leading to false-negative results. It is important
Occult blood testing is typically done as a one-time test unless otherwise specified by a healthcare provider. Collecting a specimen once each week for four weeks is unnecessary unless specifically instructed by the healthcare provider.
Correct Answer is C
Explanation
Grapes are round and can easily get stuck in a child's throat, leading to choking. The other foods listed (corn, oranges, and potatoes) are less likely to cause choking because they can be cut into smaller pieces or are less likely to get stuck in a child's airway.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.