A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

"I should use canned instead of frozen vegetables."

"I can season my foods with lemon juice."

"I should use salt sparingly while cooking."

"I can use baking soda when I bake."

Answer and Explanation

The Correct Answer is B

A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. WBC count 15,000/mm3 B. Sodium 130 mg/dL C. BUN 8 mg/dL D. Hematocrit 35%

Correct Answer is A

Explanation

A high WBC count (leukocytosis) indicates an inflammatory response to an infection, such as pneumonia. The nurse should expect to see this value in a client who has pneumonia and monitor the client for signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). The other values are within normal or expected ranges for a client who has pneumonia.

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A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching?

Nursing Test Bank

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