A nurse is contributing to the plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
Increase the client’s sodium intake.
Decrease the client’s fluid intake.
Increase the client’s saturated fat intake.
Decrease the client’s carbohydrate intake
The Correct Answer is B
Choice A: Increase the client’s sodium intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s sodium intake can worsen fluid retention and exacerbate ascites. The nurse should recommend limiting the client’s sodium intake to less than 2 g per day.
Choice B: Decrease the client’s fluid intake. This is an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. Ascites is a complication of cirrhosis that involves the accumulation of fluid in the peritoneal cavity. Decreasing the client’s fluid intake can help reduce fluid retention and prevent further distension of the abdomen and pressure on the diaphragm.
Choice C: Increase the client’s saturated fat intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s saturated fat intake can increase the risk of cardiovascular disease, obesity, and faty liver disease. The nurse should recommend a balanced diet that provides adequate protein, calories, vitamins, and minerals.
Choice D: Decrease the client’s carbohydrate intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Decreasing the client’s carbohydrate intake can cause ketosis, which is a metabolic state that occurs when the body uses fat as a fuel source instead of glucose.
Ketosis can cause nausea, fatigue, headache, and bad breath. The nurse should recommend a moderate carbohydrate intake that provides enough glucose for energy and prevents ketosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, fluid imbalance, or shock, but these are not as urgent as relieving the client’s pain.
Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their fluid status and nutritional needs, but this can be done after addressing the client’s pain.
Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and affect their quality of life.
Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.
Correct Answer is D
Explanation
Choice A: Peri-umbilical area. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The peri-umbilical area is the area around the navel, which is part of the skin. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Choice B: Nail beds. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
Choice C: Webbed areas of the fingers. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The webbed areas of the fingers are part of the skin that can show jaundice, but they may also be influenced by other factors such as temperature, circulation, or pressure.
Choice D: Hard palate. This is an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis, which is an inflammation of the gallbladder. Jaundice is a yellowish discoloration of the skin and mucous membranes due to elevated bilirubin levels in the blood. Bilirubin is a pigment that is produced from the breakdown of red blood cells and is normally excreted in bile. If the gallbladder or bile ducts are inflamed or obstructed, bile cannot flow into the duodenum and bilirubin accumulates in the blood and tissues. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
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