A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)
Encourage weight lifting during physical therapy
Measure the client's abdominal girth.
Administer warfarin.
Administer furosemide.
Implement a low-sodium diet.
Correct Answer : B,D,E
A. Encourage weight lifting during physical therapy:
Encouraging weight lifting or strenuous physical activities might not be advisable for individuals with advanced cirrhosis. Engaging in intense physical activity could potentially strain the liver or increase the risk of injury or bleeding, which is already heightened in individuals with cirrhosis.
B. Measure the client's abdominal girth:
Monitoring the client's abdominal girth is essential because cirrhosis can lead to the accumulation of fluid in the abdomen, known as ascites. Changes in abdominal girth can indicate the progression or resolution of ascites, guiding treatment and interventions.
C. Administer warfarin:
Administering warfarin, an anticoagulant, might not be ideal in cirrhosis due to the increased risk of bleeding. Liver dysfunction in cirrhosis can impair the production of clotting factors, increasing the risk of bleeding complications.
D. Administer furosemide:
Furosemide, a diuretic, can be utilized in managing ascites by promoting the elimination of excess fluid. However, its use requires careful monitoring, considering the electrolyte balance and potential adverse effects, especially in individuals with liver impairment.
E. Implement a low-sodium diet:
A low-sodium diet is crucial in managing cirrhosis-related complications, particularly ascites and edema. Sodium restriction helps reduce fluid retention, lessening the burden on the liver and alleviating symptoms associated with fluid accumulation.
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Related Questions
Correct Answer is D
Explanation
A. Provide oral hygiene.
Providing oral hygiene is important for the client's comfort and overall well-being. However, in the context of acute pancreatitis, the immediate priority is to address the gastrointestinal symptoms and prevent further pancreatic stimulation.
B. Assist the client to a side-lying position.
Assisting the client to a side-lying position can be beneficial for comfort and may help prevent complications such as aspiration. However, it is not the immediate priority after treating the pain. Withholding oral fluids and food takes precedence in the initial management of acute pancreatitis.
C. Auscultate the client's lungs.
Auscultating the client's lungs is a routine nursing assessment and is important for respiratory monitoring. However, in the context of acute pancreatitis, the primary focus is on addressing gastrointestinal symptoms, and respiratory assessment becomes more critical if respiratory distress is suspected.
D. Withhold oral fluids and food.
Withholding oral fluids and food is the priority intervention after treating the pain in acute pancreatitis. This is done to reduce pancreatic stimulation, allowing the pancreas to rest and recover. NPO (nothing by mouth) status is often initiated in the early management of acute pancreatitis.
Correct Answer is C
Explanation
A. Instruct the client that they can lift over 20 lbs:
Lifting heavy objects should be avoided postoperatively to prevent strain on the surgical site. The specific weight restriction may vary, but lifting heavy objects is generally discouraged.
B. Offer the client ice cream postoperatively:
While offering ice cream may be a comforting measure, it is not a specific action related to the recovery from a laparoscopic cholecystectomy.
C. Encourage ambulation once fully awake:
This is the correct action. Encouraging ambulation helps prevent complications such as blood clots and promotes recovery after laparoscopic surgery. Early mobility is generally encouraged unless contraindicated for specific reasons.
D. Place the client in a supine position postoperatively:
The position of the client postoperatively depends on the specific surgical procedure and the surgeon's preferences. However, placing the client in a supine position alone is not a comprehensive postoperative care action.
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