A client with hepatic failure has an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours.
What intervention should the nurse include in the plan of care?
Use a cushion when sitting.
Offer a high protein diet.
Provide only distilled water.
Document abdominal girth.
The Correct Answer is D
Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.
Choice B rationale
Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.
Choice C rationale
Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.
Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["60"]
Explanation
Step 1: We know that the medication is labeled as “750 mcg/2.4 mL”. This means that every 2.4 mL of the medication contains 750 mcg of teriparatide.
Step 2: We need to find out how many mL of the medication contains 60 mcg of teriparatide. We can set up a proportion to solve this: 750 mcg : 2.4 mL = 60 mcg : x mL Step 3: Solving for x gives us: x = (60 mcg * 2.4 mL) ÷ 750 mcg Step 4: Calculating the above expression gives us: x =
0.192 mL So, the nurse should administer 0.192 mL of the medication to deliver a dose of 60 mcg of teriparatide.
Correct Answer is C
Explanation
Choice A rationale
Replacing the IV site with a smaller gauge is not the most appropriate intervention in this situation. The client’s confusion and picking at the dressing and tape are likely due to the dementia and increased confusion at night, known as “sundowning”. While a smaller gauge might be less noticeable to the client, it does not address the primary issue of the client’s confusion and restlessness at night.
Choice B rationale
Applying soft bilateral wrist restraints might be considered in some situations to prevent a confused client from removing necessary medical devices. However, restraints should be a last resort after all other interventions have been tried because they can increase agitation and confusion, and they pose a risk for injury.
Choice C rationale
Redressing the abdominal incision is the correct choice. The dressing is no longer occlusive, which means it’s not providing a proper barrier to bacteria. This could lead to an infection in the surgical site. The nurse should clean the area and apply a new sterile dressing.
Additionally, the nurse should continue to monitor the client’s behavior and implement interventions to reduce confusion and restlessness, such as reorienting the client and providing a quiet and calm environment.
Choice D rationale
Leaving the lights on in the room at night can actually increase confusion and agitation in clients with dementia. It can disrupt the client’s sleep-wake cycle and make “sundowning” worse. Therefore, this is not the most appropriate intervention.
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