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    ATI N480 Advanced Med Surg proctored Exam_
    Select All That Apply

    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)

    Explanation & Rationale

    Choice A reason: A high-sodium diet is contraindicated in cirrhosis, as it promotes fluid retention, worsening ascites and edema. A low-sodium diet is recommended to manage fluid balance, making this choice incorrect for the care plan. Choice B reason: Daily weighing monitors fluid status in cirrhosis, as weight gain indicates ascites or edema, common complications. This helps assess treatment efficacy, like diuretics, and guides fluid management, making this a correct action. Choice C reason: Furosemide, a diuretic, reduces ascites and edema in cirrhosis by promoting fluid excretion. It addresses fluid overload, a common issue due to portal hypertension, making this a correct action for the care plan. Choice D reason: Strenuous exercise is contraindicated in cirrhosis, as it risks variceal bleeding and fatigue due to compromised liver function. Light activity may be encouraged, but strenuous efforts are unsafe, making this choice incorrect. Choice E reason: Warfarin is contraindicated in cirrhosis, as the liver’s impaired clotting factor synthesis increases bleeding risk. Anticoagulants worsen coagulopathy, particularly with esophageal varices, making this choice incorrect for the care plan.

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