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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Accepting that sexual activity will decrease does not necessarily indicate acceptance of a new altered body image. It may reflect a misunderstanding or fear about the impact of the colostomy.

Choice B rationale

Denying feelings of sadness about the ostomy does not necessarily indicate acceptance of a new altered body image. It may suggest that the patient is not fully acknowledging the emotional impact of the change.

Choice C rationale

Participating in performing ostomy care is a positive sign that the patient has accepted their new altered body image. It shows that the patient is taking an active role in their care and adapting to the change.

Choice D rationale

Preferring not to look at the stoma site does not indicate acceptance of a new altered body image. It may suggest avoidance or denial.

A. Have the client drink contrast medium. B. Shave the client from axillae to groin. C. Ensure the signed consent is in the medical record. D. Administer a cleansing enema.

Correct Answer is C

Explanation

Choice A rationale

Drinking contrast medium is not typically required for an esophagogastroduodenoscopy (EGD). Contrast media are often used in imaging studies such as CT scans or certain types of X- rays, not for EGD45.

Choice B rationale

Shaving the client from axillae to groin is not necessary for an EGD. This might be required for certain types of surgeries, but an EGD is a non-surgical procedure that involves inserting a flexible tube with a light and camera into the esophagus, stomach, and duodenum.

Choice C rationale

Ensuring the signed consent is in the medical record is crucial before any procedure, including an EGD45678. It is a legal and ethical requirement that ensures the client is informed about the procedure, its purpose, its risks and benefits, and any alternatives.

Choice D rationale

Administering a cleansing enema is not typically required for an EGD. While bowel preparation, such as using a laxative or enema, might be necessary before some procedures like a colonoscopy, it is not usually needed for an EGD45.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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