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.

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Correct Answer is A

Explanation

A. Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B. Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C. Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D. Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.

Correct Answer is ["0.2"]

Explanation

Step-by-step Calculation:

We need to find the volume (in mL) of teriparatide that contains the desired dose of 60 mcg.
Set up the proportion:

dose (mcg) / concentration (mcg/mL) = volume (mL)

Fill in the known values:
- Dose (mcg): 60 mcg (as given in the problem)
- Concentration (mcg/mL): 750 mcg/2.4 mL (from the medication label)
Solve for the volume:
- Multiply both sides of the proportion by the concentration to isolate the volume on the left:
- dose (mcg) = volume (mL) concentration (mcg/mL)
- Substitute the known values:
- 60 mcg = volume (mL) (750 mcg / 2.4 mL)
Calculate the volume:
- Divide both sides by the concentration to solve for the volume:
- volume (mL) = 60 mcg / (750 mcg / 2.4 mL)
- Simplify:
- volume (mL) = (60 mcg 2.4 mL) / 750 mcg
- volume (mL) = 0.192 mL (approximately)
Rounding (optional): The problem specifies rounding to the nearest tenth. Since 0.192 is closer to 0.2 than 0.1, the rounded volume is:
volume (mL) = 0.2 mL (rounded to one decimal place)

Therefore, the nurse should administer 0.2 mL of teriparatide.

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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?

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Naxlex Comprehensive Predictor Exams

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Correct Answer is A

Explanation

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.2"]

Explanation

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