A client with cirrhosis of the liver is experiencing ascites. The nurse should implement which of the following interventions?

Correct Answer: D

Rationale: Corrected Rationale: Ascites, the accumulation of fluid in the abdominal cavity, is a common complication of cirrhosis. Diuretics are the primary intervention to manage ascites by promoting the excretion of excess fluid from the body, thus reducing abdominal swelling. Restricting fluid intake (Choice A) would not be appropriate as it may lead to dehydration. Increasing sodium intake (Choice B) is contraindicated as it can worsen fluid retention. Encouraging a high-protein diet (Choice C) is not directly related to managing ascites.

Correct Answer: C

Rationale: The correct answer is C: Tachycardia. Albuterol can cause tachycardia as a side effect due to its stimulant effect on the heart. It acts as a beta-2 adrenergic agonist, leading to increased heart rate. Hypoglycemia (choice A) is not a common side effect of albuterol. Hyperkalemia (choice B) is also not typically associated with albuterol use. Hypotension (choice D) is less likely to occur as albuterol usually causes tachycardia rather than hypotension.

Correct Answer: A

Rationale: The correct answer is A: 'Has increased airway obstruction.' High-pitched wheezes extending throughout exhalation indicate a worsening airway obstruction, leading to increased resistance in the airways. Low-pitched wheezes present on the final half of exhalation may suggest some level of obstruction, but the change to high-pitched wheezes throughout exhalation indicates a progression in the obstruction. Choice B is incorrect as the change in wheeze characteristics signifies deterioration rather than improvement. Choice C is incorrect as suctioning is not indicated based on the wheeze assessment findings. Choice D is incorrect as hyperventilation does not typically present with wheezes and is not supported by the information provided.

Correct Answer: A

Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.

Correct Answer: B

Rationale: The correct answer is to inspect the nares and ears for skin breakdown. This is important because the nasal cannula can cause skin breakdown due to prolonged use and friction. Ensuring that the skin is intact helps prevent complications. Choice A is incorrect as oxygen therapy via a nasal cannula does not involve mist. Choice C is incorrect as lubricating the tips of the cannula is not a standard practice and may lead to complications. Choice D is incorrect because while cleanliness is important, maintaining sterile technique is not necessary for handling a nasal cannula in this context.