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.
c. Place the patient on a pressure-relieving mattress.
The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take the pressure off areas such as the sacrum that are vulnerable to breakdown.
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