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
Milky fluid often indicates chylothorax, a condition where lymphatic fluid leaks into the pleural space, and is not necessarily indicative of infection.
Choice B rationale
Bloody fluid may indicate trauma or malignancy but not necessarily infection.
Choice C rationale
Viscous fluid can be related to various conditions, including malignant effusion, but does not specifically indicate infection.
Choice D rationale
Purulent fluid is indicative of an infection as it contains pus, which is a collection of dead white blood cells, bacteria, and tissue debris.
Correct Answer is D
Explanation
Choice A rationale
Decreased serum lipase is not expected in acute pancreatitis; rather, lipase levels are typically elevated due to pancreatic enzyme leakage into the bloodstream.
Choice B rationale
Increased serum calcium is not a typical finding in acute pancreatitis; instead, hypocalcemia can occur due to fat necrosis and soap formation.
Choice C rationale
Decreased WBC is not expected; an elevated WBC count is common due to the inflammatory response associated with pancreatitis.
Choice D rationale
Increased serum amylase is a hallmark of acute pancreatitis as the damaged pancreas releases more amylase into the blood.