Question

A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?

a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Place the patient on a pressure-relieving mattress.
d. Perform passive range of motion daily.

Answer 1

The nursing action that will be included in the plan of care for a 38-year-old patient with cirrhosis, ascites, and 4+ edema of the feet and legs is to reposition the patient every 4 hours.

Step-by-step explanation:

The nursing action that will be included in the plan of care for a 38-year-old patient with cirrhosis, ascites, and 4+ edema of the feet and legs is to reposition the patient every 4 hours. Repositioning the patient helps to prevent pressure ulcers and promotes blood circulation, which can help reduce swelling in the legs and feet. Additionally, it is important to keep the legs elevated to assist with drainage and decrease fluid accumulation in the lower extremities. Therefore, placing the patient on a pressure-relieving mattress and performing passive range of motion exercises may also be included in the plan of care, but the priority action would be to reposition the patient every 4 hours.