MEDizzy - A client with cirrhosis is admitted to the hospital with

Feed Library Learning Discuss Leaderboard Journal

GIT

A client with cirrhosis is admitted to the hospital with fatigue, shortness of breath, ascites, and 3-plus pedal edema. The client has bruises on the hands and arms, is afebrile, with heart rate of 114, respirations 28, and BP at 110/85. Hemoglobin is 8 g/dl. Which of the following nursing goals is a priority for this client?

ExplanationThis client has many needs, but the nurse’s priority is to reduce ascites; the nurse keeps the client on bed rest to aid diuresis, administers diuretics as ordered, and restricts fluid intake if indicated. The client has impaired skin integrity from ascites and poor nutritional state. The client is anemic; therefore, the nurse promotes high-calorie, moderateprotein foods and supplementary feedings. Because the client is at risk for bleeding (as indicated by the bruising), the nurse assesses for signs of external and internal bleeding.