The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Provide only distilled water.

Document abdominal girth.

Offer a high protein diet.

Use a cushion when sitting.

Answer and Explanation

The Correct Answer is B

A.   Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B.   Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D.   Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C","F","G"]

Explanation

A. Humidifier bottle

Rationale: A humidifier bottle is often used with oxygen therapy to add moisture to the oxygen, preventing dryness of the nasal passages and throat. It is important for patient comfort, especially when oxygen is administered at higher flow rates for prolonged periods.

B. Lamb's wool

Rationale: Lamb's wool is not needed for starting oxygen therapy. It is typically used to provide padding and comfort in other situations, such as preventing pressure sores, but it has no role in the administration of oxygen.

C. Flowmeter

Rationale: A flowmeter is necessary to regulate the flow rate of oxygen. It ensures that the client receives the prescribed amount of oxygen (3 L/minute in this case), making it an essential component for administering oxygen therapy.

D. Tape

Rationale: Tape is not required for administering oxygen via a nasal cannula. It might be used to secure tubing in other contexts, but it is not specifically needed for starting oxygen therapy. The nasal cannula usually stays in place without the need for tape.

E. Suction cannister

Rationale: A suction canister is used in suctioning procedures to collect secretions and is not needed for starting oxygen therapy. It is relevant for managing airway secretions but unrelated to the administration of oxygen.

F. Nasal cannula

Rationale: A nasal cannula is the device through which oxygen is delivered to the client. It is specifically mentioned in the order and is essential for administering the oxygen.

G. Sterile water

Rationale: Sterile water is used to fill the humidifier bottle to provide humidified oxygen. This helps to prevent the drying effects of oxygen therapy on the mucous membranes, enhancing patient comfort.

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. B. The choice of treatment is best determined by the sensitivity of these genetic markers. C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. D. The prognosis of breast cancer is most successful when these markers are inherited mutations.

Correct Answer is C

Explanation

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. This is not accurate; BRCA1 and BRCA2 genes are involved in DNA repair, and mutations in these genes increase cancer risk.
B. The choice of treatment is best determined by the sensitivity of these genetic markers. While genetic markers can influence treatment decisions, this option does not directly address the role of BRCA1 and BRCA2 mutations in cancer risk.
C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. This is correct. Mutations in these genes significantly increase the risk of developing breast and ovarian cancer.
D. The prognosis of breast cancer is most successful when these markers are inherited mutations.
This statement is incorrect. The presence of BRCA1 or BRCA2 mutations influences risk, not necessarily prognosis or treatment success.

View Question and Answer

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

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

Correct Answer is ["A","C","F","G"]

Explanation

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?

After receiving report, the nurse can most safely plan to assess which client last?

Exhibits here Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?