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.)

Implement a low-sodium diet.

Administer furosemide.

Administer warfarin.

Measure the client's abdominal girth.

Encourage weight lifting during physical therapy.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Implementing a low-sodium diet helps reduce fluid retention and ascites in clients with cirrhosis, improving their condition.

Choice B rationale

Furosemide is a diuretic that helps reduce fluid overload and ascites in clients with cirrhosis by promoting excretion of excess fluid.

Choice C rationale

Warfarin is an anticoagulant and is not typically used in the management of cirrhosis as it could increase the risk of bleeding complications, especially in clients with liver dysfunction.

Choice D rationale

Measuring the client's abdominal girth is crucial for monitoring the progression of ascites, a common complication of cirrhosis.

Choice E rationale

Encouraging weight lifting is not advisable as it can exacerbate varices and increase the risk of bleeding in clients with cirrhosis.

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Correct Answer is C

Explanation

Choice A rationale

Temperature of 36.1°C (97.0°F) is below normal range and not indicative of organ rejection. Organ rejection often presents with elevated temperature due to the inflammatory response of the immune system attacking the transplanted organ.

Choice B rationale

Weight loss is not a common sign of acute organ rejection. Usually, fluid retention and associated weight gain can occur due to decreased kidney function.

Choice C rationale

Oliguria (reduced urine output) is a primary sign of kidney transplant rejection. It indicates that the transplanted kidney is not functioning properly, which is a critical indicator of rejection.

Choice D rationale

Insomnia is not typically associated with organ rejection. It can be related to stress or other factors but is not a direct sign of rejection.

A. Breast cancer survivor for 8 years. B. 65 years of age. C. Alcohol use disorder. D. Pacemaker.

Correct Answer is C

Explanation

Choice A rationale

A breast cancer survivor for 8 years without recurrence is generally considered for transplantation if otherwise healthy.

Choice B rationale

Age 65 is not an absolute contraindication for kidney transplantation. Many factors such as overall health status are considered.

Choice C rationale

Alcohol use disorder is a contraindication due to the potential for poor adherence to post-transplant care and medication, as well as the increased risk of liver damage.

Choice D rationale

Having a pacemaker is not an absolute contraindication for a kidney transplant; individuals with pacemakers can still be eligible for transplantation if otherwise healthy.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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.)