A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
Use a cushion when sitting.
Perform range of motion exercises.
Document abdominal girth.
Weigh every morning.
The Correct Answer is D
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
A. Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.
B. Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.
C. Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: Never scratch under the cast.
Choice A rationale:
It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.
Choice B rationale:
While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.
Choice C rationale:
Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.
Choice D rationale:
Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.
Correct Answer is A
Explanation
Choice A rationale:
Pantoprazole is a proton pump inhibitor used to treat GERD by reducing stomach acid production. If the client reports not experiencing heartburn after eating lunch, it indicates that the medication is effectively reducing stomach acid and alleviating GERD symptoms.
Choice B rationale:
The ability to swallow food without difficulty is not directly related to the desired effect of pantoprazole. It may be an important aspect of the client's overall condition, but it does not specifically indicate the efficacy of the medication in treating GERD.
Choice C rationale:
Having no difficulty straining for a bowel movement is unrelated to the desired effect of pantoprazole in treating GERD. Pantoprazole does not directly influence bowel movements.
Choice D rationale:
Having a great appetite and feeling hungry are not relevant indicators of the effectiveness of pantoprazole in treating GERD. These statements are more related to the client's appetite and overall well-being rather than the response to the medication.
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