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 D

Explanation

A. Provide high protein snacks. High protein snacks may exacerbate the symptoms of CKD by increasing urea and creatinine levels further. It is not recommended.
B. Administer PRN oxygen. Oxygen therapy is not indicated based on the symptoms described and the laboratory findings of elevated BUN and serum creatinine.
C. Monitor glucose levels every 4 hours. Monitoring glucose levels is not directly related to the symptoms described or the laboratory findings associated with CKD.
D. Schedule frequent rest periods. Fatigue and difficulty concentrating are common symptoms of CKD due to the buildup of waste products in the blood. Scheduling frequent rest periods can
help alleviate these symptoms and improve the client's overall well-being.

Correct Answer is ["100.0"]

Explanation

Total volume of the infusion: 50 mL (saline bag)
Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.

Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)

Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour

Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is ["100.0"]

Explanation

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