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

Use a cushion when sitting.

Offer a high protein diet.

Provide only distilled water.

Document abdominal girth.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.
Choice B rationale

Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.
Choice C rationale
Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.
Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.

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Correct Answer is D

Explanation

Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.

Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.

A. Lamb’s wool B. Sterile water C. Tape D. Suction canister E. Humidifier bottle F. Nasal cannula G. Flowmeter

Correct Answer is ["B","C","D","E","F","G"]

Explanation

Choice A rationale
Lamb’s wool is typically used for padding to prevent pressure sores and does not directly relate to the administration of oxygen therapy. Therefore, it is not necessary when a patient is put on oxygen.
Choice B rationale
Sterile water is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice C rationale
Tape can be used to secure the oxygen delivery device, such as a nasal cannula, to the patient’s face. Therefore, it is necessary when a patient is put on oxygen.
Choice D rationale
A suction canister is used to collect respiratory secretions during suctioning procedures, which may be necessary for patients with excessive secretions or difficulty clearing secretions.
Therefore, it is necessary when a patient is put on oxygen.
Choice E rationale
A humidifier bottle is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.

Choice F rationale
A nasal cannula is a device used to deliver supplemental oxygen to a patient who needs oxygen therapy. Therefore, it is necessary when a patient is put on oxygen.
Choice G rationale
A flowmeter is used in oxygen therapy to control the rate of oxygen flow to the patient. Therefore, it is necessary when a patient is put on oxygen.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is ["B","C","D","E","F","G"]

Explanation

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