A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Measure ankle circumference.

Obtain serum creatinine levels daily.

Ensure client takes a diuretic every morning.

Monitor daily sodium intake.

Answer and Explanation

The Correct Answer is C

Rationale

A. This intervention is important for assessing peripheral edema, which can indicate fluid overload. While relevant, it is not the highest priority in addressing acute weight gain and elevated blood pressure.

B. Daily monitoring of serum creatinine is important but is more relevant once diuretic therapy is initiated to assess renal function and electrolyte balance.

C. This option is crucial because diuretic therapy is aimed at correcting fluid imbalance in SIADH. However, the timing and dosage of diuretics should be adjusted based on clinical assessment and not solely on a fixed morning administration.

D. Monitoring sodium intake is a long-term strategy in managing SIADH to prevent hyponatremia. While important, it does not address the immediate concerns of fluid overload and elevated blood pressure.

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Correct Answer is D

Explanation

Rationale

A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.

B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.

C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.

D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.

A. Baked potato with skin, raw carrots. B. Pancakes, whole-grain cereals. C. Roasted turkey, canned vegetables. D. Roast pork, fresh strawberries.

Correct Answer is C

Explanation

Rationale

A. Both baked potato with skin and raw carrots are high-fiber foods. The skin of the potato and raw carrots contain significant amounts of fiber, which can aggravate symptoms of ulcerative colitis.

B. Whole-grain cereals are high in fiber, which is not suitable for a low-fiber diet recommended for ulcerative colitis.

C. Roasted turkey is a lean protein source and generally suitable for a low-fiber diet. Canned vegetables can vary in fiber content; however, they are typically lower in fiber compared to fresh vegetables. The nurse should verify the specific type of canned vegetables to ensure they are low in fiber.

D. Fresh strawberries are high in fiber and should be avoided on a low-fiber diet.

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A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

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Correct Answer is D

Explanation

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

Correct Answer is C

Explanation

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