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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.

Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.

Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.

Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.

A. A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy B. A client who has cervical cancer and an internal radioactive implant C. A client who had a radical mastectomy 36 hr ago and has a surgical drain D. A client who had a lobectomy and has a chest tube drainage system

Correct Answer is C

Explanation

The client who had a radical mastectomy 36 hours ago and has a surgical drain is the most stable among the given options and is further along in the recovery process. This client may be ready for discharge with appropriate follow-up care instructions, and their bed can be utilized for the incoming clients who were injured in a tornado.

The client who had a cerebrovascular accident 8 hours ago and received thrombolytic therapy requires close monitoring and assessment for complications, such as bleeding or changes in neurological status.

The client with cervical cancer and an internal radioactive implant requires specific precautions and monitoring to ensure radiation safety and to manage any potential side effects or complications.

The client who had a lobectomy and has a chest tube drainage system needs continued monitoring of respiratory status and drainage, as well as close observation for any signs of complications or worsening condition.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who has end-stage kidney disease. The client has decided to stop dialysis treatment. Which of the following actions should the nurse take?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement?

A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?