A nurse is caring for a client who has been admitted to the hospital.
Select the 5 actions the nurse should take.
Provide frequent rest periods for the client.
Instruct the client to avoid blowing their nose forcefully.
Assess the client s level of orientation.
Place the client on a low-carbohydrate diet.
Restrict the client's sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client under contact isolation.
Correct Answer : A,B,C,E,F
A: Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B: Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D: Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Isolate the client from staff who are pregnant.
Choice A rationale: Aspirin should not be administered to children or adolescents with viral infections like rubella due to the risk of Reye's syndrome, a potentially fatal condition that causes liver and brain damage.
Choice B rationale: Rubella (German measles) is particularly dangerous for pregnant women because it can cause congenital rubella syndrome in the fetus, leading to severe birth defects. Therefore, isolating the client from pregnant staff is crucial to prevent exposure.
Choice C rationale: Airborne precautions are not necessary for rubella. Rubella is transmitted through respiratory droplets, so droplet precautions, not airborne precautions, are appropriate.
Choice D rationale: Koplik spots are associated with measles (rubeola), not rubella. Therefore, monitoring for Koplik spots is not relevant for a client with rubella.
Correct Answer is B
Explanation
The correct answer is choice B. The client should keep the medication in the original container.
Dabigatran is a blood thinner that is used to prevent strokes or blood clots in people with atrial fibrillation, a type of irregular heartbeat. Dabigatran is sensitive to moisture and can lose its potency if exposed to humidity or heat. Therefore, it is important to store it in the original bottle or blister package that has a desiccant (drying agent) in the cap or cover. The client should also close the cap tightly after each use and keep the bottle away from excessive moisture, heat, and cold.
Choice A is wrong because storing the medication in the refrigerator can expose it to moisture and cause it to break down. Choice C is wrong because crushing the medication and mixing it with applesauce can alter its absorption and effectiveness. Choice D is wrong because the medication can be used up to 60 days after opening the bottle as long as it is stored properly. The normal dose of dabigatran for stroke prevention in atrial fibrillation is 150 mg twice a day, unless the client has kidney problems or other factors that require a lower dose.
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