Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
A nurse is caring for a client who has been admitted to the hospital. Nurses' Notes 0900: The client reports experiencing a loss of appetite and shortness of breath within the last month or so. The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably. The client is alert but disoriented to time. Their abdomen is bloated and they have redness of the palms of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow. 1230: Administered antacids, spironolactone, and colchicine per provider's prescription. Laboratory Results 1200: Hgb 9.5 g/dL(14 ta 18 g/dL) Hct 38%(42% to 52%) Bilirubin 5,3 mg/dL(0.3 ta 1.0 mg/dL) Creatinine 1.8 mg/di.(0,6 to 1.3 mg/dU) Platelet count 100,000/mm\*(150,000 to 400,000/mmn) 1800: Alanine aminotransferase ALT 51 units/L(4 to 36 units/L) Aspartate aminotransferase AST 48 units/L(0 to 35 units/L) Alkaline phosphate ALP 151 units/L(30 to 120 units/L) Blood total protein 15 g/di.(6.4 to 8.3 g/dL)Select the 5 actions the nurse should take.
Correct answer
A,B,C,E,F,G
Rationale
The correct actions the nurse should take are A, B, C, E, F, and G. A: Providing rest periods promotes healing. B: Restricting sodium intake is crucial for certain health conditions. C: Avoiding soap and alcohol-based lotions can prevent skin irritation. E: Placing the client under contact isolation is necessary to prevent the spread of infection. F: Instructing the client to avoid blowing their nose forcefully prevents injury. G: Assessing the client's level of orientation is essential for monitoring their mental status. Other choices are incorrect because a low-carbohydrate diet (D) is not mentioned, and it is not a priority action in this scenario.