The nurse is admitting a client with liver disease who presents with dyspnea, weight gain and abdominal distention. Which order would the nurse anticipate?
Check blood glucose every 4 hours
2 gram sodium diet
Bedrest
Insert indwelling urinary catheter
The Correct Answer is B
A) Monitoring blood glucose is more relevant for diabetic care.
B) A sodium diet is appropriate for managing fluid retention associated with liver disease.
C) Bedrest may be prescribed but not as specific to the management of fluid retention.
D) Insertion of an indwelling urinary catheter is not a standard intervention without additional justification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Cirrhosis can lead to coagulopathy due to impaired synthesis of clotting factors by the liver, putting the client at high risk for bleeding.
B) While clients with cirrhosis may experience fatigue, it is not the priority problem indicated by the assessment data provided.
C) Decreased appetite and jaundice may affect nutritional status, but they do not pose an immediate threat compared to the risk of bleeding.
D) Jaundice can lead to pruritus and increased risk of skin breakdown, but it is not the priority problem indicated by the assessment data provided.
Correct Answer is A
Explanation
A) These are dilated veins in the esophagus that can rupture and lead to life- threatening bleeding.
B) While concerning and indicative of hepatic encephalopathy, it is not immediately life-threatening like a variceal bleed.
C) Indicates poor nutritional status and liver function but is not as acutely dangerous as bleeding varices.
D) This is a concern but does not represent an immediate life-threatening condition like esophageal varices.
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