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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect- This response might address the client's concern but doesn't directly address her dichotomous thinking or provide immediate therapeutic communication.
B) Incorrect- While showing happiness for the client's improvement is positive, this response does not address the client's behavior or engage with her dichotomous tendency.
C) Incorrect- This response acknowledges the client's liking but doesn't address the dichotomous thinking pattern or provide an effective therapeutic response.
D) Correct- answering this question encourages the client to express her concerns and perceptions, fostering communication. This approach acknowledges the client's feelings and provides an opportunity for her to discuss the issue, potentially leading to a productive conversation.
Correct Answer is B
Explanation
A) Incorrect - The APTT value being two times the control value indicates that the client's anticoagulation is within the therapeutic range. There is no need to increase the warfarin dose.
B) Correct - With the APTT value within the target range and the PT and INR values also normal, the nurse should continue the same dose of warfarin and withhold the heparin.
C) Incorrect - Decreasing the heparin dose is not indicated, as the client's APTT is already within the therapeutic range.
D) Incorrect - Increasing the heparin dose and decreasing the warfarin dose is not necessary, as the client's anticoagulation levels are appropriate.
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