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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.)

A.

Implement a low-sodium diet.

B.

Administer furosemide.

C.

Administer warfarin.

D.

Measure the client's abdominal girth.

E.

Encourage weight lifting during physical therapy.

Question Solution

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 ["A","B","D"]

Explanation

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.

Correct Answer is A

Explanation

Choice A rationale

Agitation is a common manifestation of hypoxemia due to insufficient oxygen reaching the brain and other vital organs.

Choice B rationale

Dysphagia, or difficulty swallowing, is not a typical manifestation of hypoxemia during an asthma attack.

Choice C rationale

Nausea can occur but is not a primary indicator of hypoxemia.

Choice D rationale

Hypotension may occur with severe hypoxemia but is not a direct manifestation of asthma-related hypoxemia.

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