The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a resident of the long-term care facility is reporting eye pain and photophobia. The resident is being treated for bacterial conjunctivitis. Upon entering the resident's room, the PN observes that the UAP has darkened the room and placed a warm compress over the resident's eyes. Which action should the PN take?

Choice A rationale:

Offering a high protein diet may not be appropriate for a client with hepatic failure. High protein intake can lead to the accumulation of ammonia in the bloodstream, worsening hepatic encephalopathy. Therefore, this choice is not the best intervention for the client.

Choice B rationale:

Performing range of motion exercises is important for clients with hepatic failure to prevent complications related to immobility. However, it does not directly address the client's elevated pulse rate and changes in mental status.

Choice C rationale:

Weighing the client every morning is essential in monitoring fluid status and identifying signs of fluid retention or dehydration, which are common in hepatic failure. Changes in weight can help detect early signs of worsening hepatic function.

Choice D rationale:

Providing only distilled water may not be appropriate for a client with hepatic failure. While it is essential to monitor fluid intake, restricting all fluids to only distilled water could lead to electrolyte imbalances and further complications. Monitoring overall fluid intake and type is important for these clients.

Suction the trachea.

Choice A rationale:

The practical nurse (PN) should ensure the ready availability of equipment to perform tracheal suctioning for a client who requires seizure precautions. Seizures can sometimes cause excessive salivation or even vomiting, which may lead to the obstruction of the airway. Suctioning the trachea helps in quickly clearing any secretions or vomitus from the airway, preventing potential respiratory compromise and ensuring the client's airway remains patent.

Choice B rationale:

Inserting a nasogastric tube is not directly related to seizure precautions. Nasogastric tubes are used for various purposes, such as decompression of the stomach, feeding, or administering medications. While it might be necessary in specific situations, it is not a priority when caring for a client on seizure precautions.

Choice C rationale:

Inserting a urinary catheter is also not directly related to seizure precautions. It is typically done for clients who have difficulty urinating on their own or for precise monitoring of urine output. Seizure precautions focus on the client's airway and safety during a seizure episode.

Choice D rationale:

Applying soft restraints is generally not recommended for clients on seizure precautions. Restraints should only be used as a last resort for clients who pose a risk to themselves or others during a seizure. The primary goal is to provide a safe environment and prevent injuries without restraining the client unless absolutely necessary.