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    Ati lpn med surg gi proctored test
    Select All That Apply

    A nurse is contributing to the plan of care for a client who has cirrhosis of the liver. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

    Explanation & Rationale

    A. Implement fall precautions: Cirrhosis patients may develop hepatic encephalopathy (confusion, asterixis), muscle weakness, and coagulopathy (increased bleeding risk). Fall precautions reduce injury risk. B. Administer enemas to manage constipation: Routine enemas are not universally indicated and can be harmful if used indiscriminately. However, bowel regulation is important - if hepatic encephalopathy is present, reducing ammonia (e.g., with lactulose or prescriber-directed interventions) is indicated; enemas might be ordered in specific situations but should not be a standing, routine nursing intervention without an order. C. Initiate a low sodium diet: Low-sodium diet helps control ascites and peripheral edema in cirrhosis by reducing fluid retention - this is a standard intervention. D. Measure abdominal girth daily: Daily abdominal girth measurement tracks ascites progression or response to diuretics/paracentesis - important for fluid management. E. Obtain a weekly weight: Weekly weight is insufficient for fluid-shift monitoring in cirrhosis; daily weights are recommended to detect small fluid changes. So weekly weight alone is not appropriate - daily weights are preferred.

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