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","B","C","D"]

Explanation

A. Blood culture is essential to identify any potential infection that the patient may have, which is a common complication after trauma.
B . Prothrombin time is crucial for assessing the blood's clotting ability, especially since the patient has a suspected fracture and could be at risk of bleeding.
C . Hemoglobin and hematocrit are fundamental tests to evaluate for anemia or blood loss, which is particularly relevant given the patient's fall and the possibility of internal injuries. D . Type and screen is necessary in case the patient requires a blood transfusion due to the injuries sustained from the fall.
E . Albumin is not typically a priority in acute trauma settings and would not necessarily be expected as an immediate test.
F . Lipid panel is not relevant in the acute management of trauma and is not typically ordered in the emergency setting

A. Measure urinary output every hour. B. Initiate seizure precautions. C. Assess pupillary response to light hourly. D. Monitor serum potassium frequently.

Correct Answer is A

Explanation

A. Measure urinary output every hour. Dopamine is commonly used to improve blood pressure and renal perfusion in hypotensive clients. Monitoring urinary output is crucial because dopamine can increase renal blood flow and urine output. Hourly measurement allows for early detection of changes in renal function and urine output, enabling prompt intervention if needed.
B. Initiate seizure precautions. Seizures are not a common adverse effect of dopamine administration. Therefore, initiating seizure precautions is unnecessary in this context.
C. Assess pupillary response to light hourly. While assessing pupillary response is important in neurological assessments, it is not a priority intervention specifically related to dopamine
administration for hypotension.

D. Monitor serum potassium frequently. Dopamine administration is not directly associated with alterations in serum potassium levels. While electrolyte monitoring is important in some
situations, it is not the primary concern when administering dopamine for hypotension. Monitoring urinary output is more pertinent in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is A

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