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 B

Explanation

Choice A rationale

Intermittent abdominal pain is not typically associated with total parenteral nutrition (TPN) or burn injuries.

Choice B rationale

Increased serum glucose levels can occur with TPN due to the high glucose content of the solution. This should be monitored closely, especially in patients with burns, who may have altered glucose metabolism.

Choice C rationale

Absent bowel sounds are not typically associated with TPN or burn injuries.

Choice D rationale

Decreased calcium levels are not typically associated with TPN or burn injuries.

A. Accepts that sexual activity will decrease. B. Denies feelings of sadness about the ostomy. C. Participates in performing ostomy care. D. Prefers not to look at the stoma site.

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.

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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

A nurse is caring for a patient who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition.The nurse should actively monitor the patient for which of the following?

Correct Answer is B

Explanation

A nurse is collecting data from a patient who has a newly placed colostomy.Which of the following findings would indicate to the nurse that the patient has accepted their new altered body image?

Correct Answer is C

Explanation

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