A nurse is caring for a client who has heart failure and has gained 2 kg (4.4 lB. over the last 24 hours. Which of the following interventions should the nurse take?
Reduce the client's sodium intake.
Restrict the client's protein intake.
Weigh the client once per week.
Provide the client with three large meals per day.
The Correct Answer is A
Choice A reason: Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
Choice B reason: Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
Choice C reason: Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
Choice D reason: Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client's creatinine level of 1.0 mg/dL is within the normal range, but it does not indicate that the treatment for benign prostatic hyperplasia has been effective. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys and excreted in urine. It reflects the kidney function, not the prostate condition.
Choice B reason: The client's urine output of 35 mL/hr is below the normal range, which is 40 to 60 mL/hr. This indicates that the client may have dehydration, kidney impairment, or urinary retention, which are complications of benign prostatic hyperplasia. A low urine output does not indicate that the treatment has been effective.
Choice C reason: The client's stool color and consistency are not related to the treatment for benign prostatic hyperplasia. Stool characteristics depend on various factors, such as diet, medication, and bowel function. A soft, brown stool does not indicate that the treatment has been effective.
Choice D reason: The client's ability to urinate without straining is a sign that the treatment for benign prostatic hyperplasia has been effective. Benign prostatic hyperplasia is a condition in which the prostate gland enlarges and compresses the urethra, causing difficulty in urination. A treatment that reduces the size of the prostate or relaxes the bladder neck muscles can improve the urine flow and reduce the straining.
Correct Answer is C
Explanation
Choice Areason: Graham crackers are made from wheat flour, which contains gluten. Peanut butter is a good source of fat and protein, but it may also contain traces of gluten from cross-contamination.
Choice Breason: Poached eggs are a good source of protein, but wheat bagel contains gluten, which is a protein found in wheat, barley, and rye. Gluten can damage the small intestine and cause malabsorption, diarrhea, and abdominal pain in people with celiac disease.
Choice C reason: Rice cereal is gluten-free and a good source of carbohydrates. Sliced bananas are gluten-free and a good source of potassium, fiber, and vitamin C.
Choice D reason: Rye toast contains gluten, which can harm people with celiac disease. Herbal tea is gluten-free and can help with hydration, but it does not provide enough calories or nutrients.
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