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 C
Explanation
The correct answer is choice C. Assign the remainder of medication administration to another PN who is performing treatments.
Choice A rationale:
Asking unlicensed assistive personnel (UAP) to give medications to their assigned residents is not the best action to take in this situation. Medication administration requires a certain level of training and knowledge to ensure safe and accurate delivery. UAPs may not have the appropriate training and legal authorization to administer medications, which could lead to potential errors and harm to the residents.
Choice B rationale:
Documenting why all the medications were not given to each resident is not sufficient to address the issue at hand. While documentation is essential for record-keeping and communication, it does not resolve the problem of medication administration being left incomplete. The priority should be finding a qualified person to administer the remaining medications.
Choice C rationale:
This is the correct answer because assigning the remainder of medication administration to another PN who is performing treatments ensures that qualified and trained personnel are handling the medication administration. This PN is likely familiar with medication protocols and safety measures, reducing the risk of errors.
Choice D rationale:
Denying the medication aide's request to leave before all medications are given might not be practical if the aide is genuinely unwell or unable to continue working safely. The focus should be on ensuring that medication administration is completed by qualified staff rather than forcing the sick aide to stay.
Correct Answer is B
Explanation
The Herpes zoster (shingles) vaccination is recommended for adults aged 60 years and older, regardless of whether they have had shingles or chicken pox before. The vaccine can reduce the risk of developing shingles and its complications, such as postherpetic neuralgia.
The other options are not correct because:
A. The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.
C. The person needs to get this vaccination even if they have had chickenpox, as shingles are caused by the reactivation of the same virus that causes chickenpox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.
D. The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.
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