A nurse is caring for a client who has been admitted to the hospital.
Select the 5 actions the nurse should take.
Provide frequent rest periods for the client.
Instruct the client to avoid blowing their nose forcefully.
Assess the client s level of orientation.
Place the client on a low-carbohydrate diet.
Restrict the client's sodium intake.
Advise the client to avoid the use of soap and alcohol-based lotions.
Place the client under contact isolation.
Correct Answer : A,B,C,E,F
A: Provide frequent rest periods for the client. This is correct because the client has anaemia (low haemoglobin and hematocrit), which can cause weakness and fatigue. Rest periods can help conserve energy and prevent complications.
B: Instruct the client to avoid blowing their nose forcefully. This is correct because the client has thrombocytopenia (low platelet count), which can increase the risk of bleeding. Blowing the nose forcefully can cause nasal bleeding or rupture of blood vessels.
C: Assess the client’s level of orientation. This is correct because the client has hepatic encephalopathy (brain dysfunction due to liver failure), which can cause confusion, mood changes, and disorientation. Assessing the client’s level of orientation can help monitor the severity of hepatic encephalopathy and guide appropriate interventions.
D: Place the client on a low-carbohydrate diet. This is incorrect because a low-carbohydrate diet can worsen hepatic encephalopathy by increasing ammonia production in the gut. The client should be on a high-protein, high-calorie diet to provide adequate nutrition and prevent muscle wasting.
E: Restrict the client’s sodium intake. This is correct because the client has ascites (fluid accumulation in the abdomen) due to portal hypertension (high blood pressure in the portal vein). Restricting sodium intake can help reduce fluid retention and prevent further complications.
F Advise the client to avoid the use of soap and alcohol-based lotions. This is correct because the client has pruritus (itching) due to high bilirubin levels in the blood. Soap and alcohol-based lotions can dry out the skin and worsen pruritus. The client should use mild cleansers and moisturizers to soothe the skin.
G: Place the client under contact isolation. This is incorrect because there is no indication that the client has an infectious disease that requires contact isolation. Contact isolation is used for clients who have diseases that can be transmitted by direct or indirect contact with the client or their environment, such as Clostridioides difficile infection or methicillin-resistant Staphylococcus aureus infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Correct Answer is D
Explanation
The correct answer is choice D. Avoid using nail polish remover around the client. Nail polish remover contains acetone, which is a flammable substance that can ignite in the presence of oxygen.
Using nail polish remover around the client can increase the risk of fire and burn injuries.
Choice A is wrong because synthetic fabrics can generate static electricity, which can also cause sparks and ignite oxygen.
The client’s bedding should be made of cotton or wool, which are natural fabrics that do not produce static electricity.
Choice B is wrong because petroleum jelly is a petroleum-based product that can react with oxygen and cause skin irritation or burns.
The client should use water-based moisturizers to soothe the mucous membranes.
Choice C is wrong because alcohol-based cleaning products are also flammable and can cause fires or explosions when exposed to oxygen.
The client should use mild soap and water to clean the equipment, and follow the manufacturer’s instructions for maintenance.
Some general safety tips for home oxygen therapy are:
- Keep away from heat and flame, such as candles, matches, lighters, stoves, fireplaces, etc.
- Do not smoke or allow others to smoke near the oxygen source
- Do not use aerosols, vapor rubs, oils, or other products that contain flammable substances near the oxygen source
- Store oxygen tanks or cylinders in a well-ventilated area away from direct sunlight and heat sources
- Secure oxygen tanks or cylinders to prevent them from falling or rolling
- Use the exact rate of oxygen prescribed by the doctor for each activity
- Check the oxygen gauge or level regularly and call the medical supply company when it is low
- Use a humidifier bottle if prescribed by the doctor to prevent dryness of the mucous membranes
- Change the nasal cannula, mask, and tubing as instructed by the medical supply company to prevent
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