A nurse is assisting with the plan of care for a patient who has heart failure. Which of the following interventions should the nurse recommend?
Offer snacks that are high in sodium.
Monitor the patient’s weight once per week.
Provide rest periods throughout the day.
Place the head of the patient’s bed flat.
The Correct Answer is C
Offering snacks that are high in sodium is not recommended for patients with heart failure. Sodium can cause fluid retention and worsen heart failure symptoms.
Choice B rationale
Monitoring the patient’s weight once per week is not sufficient for patients with heart failure. Daily weight monitoring is typically recommended to detect fluid retention early.
Choice C rationale
Providing rest periods throughout the day is recommended for patients with heart failure. Rest can help reduce the workload of the heart and manage symptoms of fatigue.
Choice D rationale
Placing the head of the patient’s bed flat is not recommended for patients with heart failure. This position can make breathing more difficult. Instead, the head of the bed should be elevated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monthly vitamin B12 injections are not a risk factor for the development of osteoporosis. Vitamin B12 is important for nerve function and the production of DNA and red blood cells, not bone health.
Choice B rationale
Long-term use of prednisone, a corticosteroid, can lead to osteoporosis. Prednisone can decrease the absorption of calcium in the gut and increase the loss of calcium in the kidneys, leading to bone loss and an increased risk of fractures.
Choice C rationale
A congenital heart murmur is not a risk factor for the development of osteoporosis. Heart murmurs are sounds during your heartbeat cycle made by turbulent blood in or near your heart, and they are not associated with bone health.
Choice D rationale
A history of kidney stones is not a risk factor for the development of osteoporosis. Kidney stones are hard deposits made of minerals and salts that form inside your kidneys, and they are not associated with bone health.
Correct Answer is C
Explanation
A.Changing the dressing on the tracheostomy site is an important part of tracheostomy care, but it is not the first action that should be taken.
B.Suctioning the tracheostomy tube should only be performed if there are signs of airway obstruction (e.g., increased secretions, decreased oxygenation, or adventitious breath sounds). Suctioning too frequently or unnecessarily can cause mucosal damage and hypoxia.
C. Auscultating the lungs helps the nurse determine if there is increased secretions, diminished breath sounds, or other airway concerns that may require suctioning. This ensures that care is performed appropriately based on the client’s needs.
D.Cleaning the inner cannula is a necessary part of tracheostomy care, but it should bedone after assessing the airway and performing suctioning if needed.
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