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 {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

A. anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.

B. arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.

C. Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.

D. Necrosis

Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.

E. Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.

F. Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.

A. Redress the abdominal incision. B. Leave the lights on in the room at night. C. Apply soft bilateral wrist restraints. D. Replace the IV site with a smaller gauge.

Correct Answer is A

Explanation

Rationale for A: Redressing the abdominal incision is crucial as the dressing is no longer occlusive, which could lead to infection. An intact dressing also prevents the client from picking at the site, which could cause further harm or delay healing.
Rationale for B: Leaving the lights on might help with visual perception for a client with dementia, but it does not directly address the immediate risk of infection or the client's interference with the dressing.
Rationale for C: Applying restraints could be considered for a client who is at risk of harming themselves, but this should be a last resort after other interventions have been tried due to the potential for physical and psychological harm.
Rationale for D: Replacing the IV site with a smaller gauge is not indicated by the pink insertion site alone and does not address the client's confusion or behavior towards the dressing.

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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

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

Correct Answer is A

Explanation

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