A client is being treated for hepatic failure. On examination, the client has an elevated pulse rate and exhibited changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
Offer a high protein diet.
Perform range of motion exercises.
Weigh every morning.
Provide only distilled water.
The Correct Answer is C
Choice A rationale:
Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.
Choice B rationale:
Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.
Choice C rationale:
Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.
Choice D rationale:
Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Culture for sensitive organisms.
- Choice A rationale:
- C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
- Choice B rationale:
- Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
- Choice C rationale:
- Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
- Choice D rationale:
- Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.
Correct Answer is D
Explanation
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment.
The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today