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    PN Comprehensive Predictor 2023 Proctored Exam

    A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

    Explanation & Rationale

    A. Measure the client's abdominal girth daily: Monitoring abdominal girth helps assess the progression or reduction of ascites and guides the effectiveness of interventions such as diuretic therapy or paracentesis. Daily measurements provide objective data for evaluating fluid accumulation. B. Position the client supine with legs elevated: Elevating the legs while supine is more appropriate for peripheral edema, not ascites. For ascites, semi-Fowler’s or upright positioning is preferred to promote comfort and reduce pressure on the diaphragm. C. Restrict the client's sodium intake to 3 g per day: Sodium restriction is typically recommended to manage fluid retention in ascites, but standard guidelines suggest limiting sodium to 2 g per day, not 3 g, to optimize effectiveness. D. Keep the client's daily protein intake below 0.8 g/kg: Clients with cirrhosis and ascites often require adequate protein to prevent muscle wasting and malnutrition. Restricting protein excessively can worsen nutritional status and is generally not recommended unless the client has hepatic encephalopathy.

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