A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?
Baked potato
Milkshake
Ham sandwich
Stewed tomatoes
The Correct Answer is C
Rationale:
A. Baked potato is low in sodium if prepared without added salt, making it safe for a client on a diuretic.
B. Milkshake is generally safe unless it contains added sodium; in most cases, it is allowed.
C. Ham is high in sodium, which is contraindicated for a client taking bumetanide, a loop diuretic, as high sodium intake can counteract the diuretic effect and worsen fluid retention.
D. Stewed tomatoes can be included if unsalted; they are generally safe in moderation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Restlessness can occur with electrolyte imbalances or hypoxia, but it is not a hallmark of low albumin or protein malnutrition.
B. Low serum albumin and total protein decrease plasma oncotic pressure, allowing fluid to shift from the vascular space into interstitial tissues, leading to peripheral and sometimes generalized edema (anasarca).
C. Pallor is more indicative of anemia, which may coexist but is not a direct effect of hypoalbuminemia.
D. Confusion can result from electrolyte disturbances, hypoxia, or hepatic encephalopathy, but it is not a direct manifestation of low albumin.
Correct Answer is ["A","B","D","F","G","H"]
Explanation
Vital Signs
- Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
- Heart rate: 122/min → tachycardia, worsened compared to earlier.
- Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.
Nurse’s Notes
- Client lethargic → worsening mental status.
- Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
- Abdominal cramping → possible gastrointestinal complication.
- Voiding dark, concentrated urine → sign of dehydration.
- Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.
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