A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

The correct answer is choice d. Measure the client’s abdominal girth daily.

Choice A rationale:

Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.

Choice B rationale:

Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.

Choice C rationale:

Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.

Choice D rationale:

Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.

The correct answer is choice C. Providing discharge teaching about home IV medication therapy.

Choice A rationale:

Administering a subcutaneous insulin injection is a task that can be delegated to a licensed practical nurse (LPN) or a trained unlicensed assistive personnel (UAP) under the supervision of an RN, as it is a routine and straightforward procedure.

Choice B rationale:

Collecting a sputum culture is also a task that can be performed by an LPN or a trained UAP. It does not require the advanced assessment skills of an RN.

Choice C rationale:

Providing discharge teaching about home IV medication therapy requires the advanced knowledge and skills of an RN. This task involves comprehensive education, assessment of the patient’s understanding, and ensuring the patient can safely manage their IV medication at home. It is critical for patient safety and effective care management.

Choice D rationale:

Removing an NG tube is a procedure that can be performed by an LPN or a trained UAP. It is a relatively simple task that does not require the advanced skills of an RN.