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
This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's attention to another topic or activity and document the incident.
A. The size of my breasts is of no concern to you is not the best response because it may sound defensive or sarcastic and may not deter the adolescent from making similar comments in the future.
C. Do you really think so? is not the best response because it may encourage or reinforce the adolescent's inappropriate or sexual comments and may imply that the PN is interested or flattered by them.
D. If you talk like that again, I will tell your parents is not the best response because it may sound threatening or punitive and may not address the underlying issue of the adolescent's behavior. The PN should inform the parents only if the behavior persists or escalates.
Correct Answer is C
Explanation
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
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