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.
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 D
Explanation
Choice A rationale
High-protein and high-carbohydrate foods are beneficial, but they do not directly address the immediate respiratory issues in ARDS.
Choice B rationale
Encouraging oral intake of fluids may not be appropriate as it can contribute to fluid overload and worsen pulmonary edema in ARDS patients.
Choice C rationale
Administering low-flow oxygen might be necessary but isn't the most crucial intervention for ARDS. High-flow oxygen or mechanical ventilation is typically required.
Choice D rationale
Placing the client in a prone position has been shown to improve oxygenation in ARDS by enhancing lung expansion and ventilation-perfusion matching.
Correct Answer is A
Explanation
Choice A rationale
Obtaining a prescription for supplemental oxygen is the first action as hypoxia must be corrected immediately to ensure adequate tissue oxygenation.
Choice B rationale
Obtaining a prescription to administer intravenous fluids is essential to address dehydration but is secondary to correcting hypoxia.
Choice C rationale
Obtaining a prescription to administer insulin is crucial to manage hyperglycemia in diabetic ketoacidosis but not the initial step in this context.
Choice D rationale
Obtaining a prescription to check the client's glucose level is necessary for monitoring but does not address the immediate need for oxygenation.