A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Choice A reason: This is incorrect because providing a diet low in phosphorus is not indicated for a client with cirrhosis of the liver. Phosphorus restriction is more relevant for clients with renal failure, not liver failure.

Choice B reason: This is correct because noting signs of swelling and edema is an essential intervention for a client with cirrhosis of the liver. Swelling and edema are signs of fluid retention and portal hypertension, which are common complications of liver disease.

Choice C reason: This is incorrect because increasing oral fluid intake to 1,500 mL daily is not advisable for a client with cirrhosis of the liver. Fluid restriction may be necessary to prevent fluid overload and ascites, which are common complications of liver disease.

Choice D reason: This is correct because monitoring abdominal girth is an important intervention for a client with cirrhosis of the liver. Abdominal girth measurement can indicate the presence and severity of ascites, which is a common complication of liver disease.

Choice E reason: This is correct because reporting serum albumin and globulin levels is a vital intervention for a client with cirrhosis of the liver. Serum albumin and globulin levels can reflect the liver's synthetic function and indicate the extent of liver damage.

Choice A reason: This is a correct answer because determining if the mother has recently experienced a fall is important to rule out any head injury or concussion that could cause confusion. Parkinson's disease can increase the risk of falls due to impaired balance, coordination, and mobility.

Choice B reason: This is not a correct answer because reviewing the client's current food and medication allergies is not relevant to the mother's confusion. However, it may be important to review the client's current medications and dosages to check for any adverse effects or interactions that could affect cognition.

Choice C reason: This is not a correct answer because encouraging increased intake of high protein foods is not helpful for the mother's confusion. In fact, high protein foods may interfere with the absorption of levodopa, a medication used to treat Parkinson's disease symptoms. The nurse should advise the daughter to consult with a dietitian about the optimal timing and amount of protein intake for her mother.

Choice D reason: This is a correct answer because instructing the daughter to check her mother's temperature is important to detect any fever or infection that could cause confusion. Older adults are more susceptible to infections such as urinary tract infections (UTIs), pneumonia, or sepsis, whih can affect mental status.

Choice E reason: This is a correct answer because asking if the mother is experiencing any pain with urination is important to screen for any UTI that could cause confusion. UTIs are common in older adults due to reduced bladder function, incomplete emptying, and decreased immunity. UTIs can cause symptoms such as dysuria, frequency, urgency, hematuria, and delirium.