A nurse is planning care for a client who has long-term liver cirrhosis and a new diagnosis of abdominal ascites. Which of the following interventions should the nurse include in the plan of care to prevent complications?
Administer furosemide.
Weigh the client weekly.
Offer the client a high-sodium diet.
Administer heparin.
None
None
The Correct Answer is A
Answer: A. Administer furosemide.
Rationales
A. Administer furosemide.
Furosemide, a loop diuretic, helps reduce fluid overload by promoting urinary excretion of sodium and water. In a client with cirrhosis and ascites, it decreases abdominal distention, eases breathing by reducing pressure on the diaphragm, and prevents complications related to severe fluid accumulation.
B. Weigh the client weekly.
Weekly weights would not provide sufficient monitoring for a client with ascites, since fluid retention can change rapidly within hours or days. Daily weights are necessary to detect subtle increases in fluid status and to evaluate the effectiveness of treatment.
C. Offer the client a high-sodium diet.
A high-sodium diet would worsen fluid retention and ascites, as sodium promotes water retention. Instead, a low-sodium diet is indicated to limit further fluid buildup in the peritoneal cavity.
D. Administer heparin.
Heparin is not a standard intervention for cirrhosis with ascites. Because the diseased liver produces fewer clotting factors, clients are already at risk for bleeding, and anticoagulant therapy would heighten this risk without addressing the underlying problem of fluid accumulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.
Choice B rationale:
Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.
Choice C rationale:
"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.
Choice D rationale:
"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.
Correct Answer is A
Explanation
Choice A rationale:
A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.
Choice B rationale:
The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice C rationale:
An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice D rationale:
A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.
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