A nurse is reinforcing discharge teaching with a client who has heart failure. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Alternate activity and rest.

Reduce sodium intake to 2 g per day.

Consume a low-fiber diet.

Gradually increase activity each day.

Eat small, frequent meals each day.

Answer and Explanation

Correct Answer : A,B,D,E

A. Alternate activity and rest. Clients with heart failure should balance activity and rest to prevent overexertion and minimize cardiac workload. Frequent rest periods help conserve energy and reduce symptoms such as dyspnea and fatigue.
B. Reduce sodium intake to 2 g per day. Limiting sodium intake helps prevent fluid retention and reduces the risk of worsening heart failure. Excess sodium contributes to increased blood volume and exacerbates symptoms such as edema and shortness of breath.
C. Consume a low-fiber diet. A low-fiber diet is not necessary for heart failure management. Adequate fiber intake is beneficial for preventing constipation, which can increase strain during bowel movements and lead to hemodynamic stress. A high-fiber diet is generally encouraged.
D. Gradually increase activity each day. Clients should slowly increase their activity level based on tolerance to improve cardiovascular function. Overexertion should be avoided, but regular, controlled exercise helps maintain mobility and enhance overall heart health.
E. Eat small, frequent meals each day. Eating smaller meals reduces gastric distension and minimizes pressure on the diaphragm, which can help alleviate shortness of breath. Large meals can increase metabolic demands and contribute to discomfort in clients with heart failure.

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Correct Answer is C

Explanation

A. Increased intake of green, leafy vegetables does not inherently increase the risk for injury in clients with thrombocytopenia. In fact, these vegetables can provide essential vitamins and nutrients. However, clients may need to monitor their intake of vitamin K if they are on anticoagulant therapy, but this does not directly correlate with injury risk related to thrombocytopenia.
B. Wears a face mask around others is a precautionary measure typically used to prevent infection, especially in immunocompromised clients. This action does not increase the risk for injury; instead, it helps protect the client from potential pathogens.
C. Uses a firm-bristled toothbrush increases the risk for injury in clients with thrombocytopenia. A firm-bristled toothbrush can cause gum irritation and bleeding due to low platelet counts, which can lead to prolonged bleeding and increase the risk of oral injuries. Soft-bristled toothbrushes are recommended to minimize the risk of bleeding.
D. Sleeps 8 to 10 hr per night is a healthy behavior that supports overall well-being and recovery. Adequate sleep can help the body heal and does not increase the risk for injury in clients with thrombocytopenia.

A. Obtain a large-bore IV catheter. B. Explain to the client that transfusion reactions are not serious. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Witness the client signing consent for transfusion.

Correct Answer is ["A","C","E"]

Explanation

A. Obtain a large-bore IV catheter. A large-bore IV catheter (18-gauge or larger) is necessary for blood transfusion to allow for rapid administration and reduce the risk of hemolysis. The provider has already prescribed this intervention.
B. Explain to the client that transfusion reactions are not serious. This statement is inaccurate and misleading. While many transfusion reactions are mild, some can be life-threatening, such as hemolytic reactions or anaphylaxis. The nurse should educate the client about signs and symptoms of a transfusion reaction and instruct them to report any discomfort or unusual sensations immediately.
C. Ensure two nurses confirm the information on the blood label. Before administering blood, two nurses must verify the blood product against the client's identification band, medical record, and blood bank documentation to prevent transfusion errors.
D. Ensure the transfusion tubing is flushed with dextrose 5% in water. Blood products should only be administered with normal saline (0.9% sodium chloride) because dextrose-containing solutions can cause red blood cell hemolysis. The nurse should ensure the IV tubing is primed with normal saline before starting the transfusion.
E. Witness the client signing consent for transfusion. Informed consent is required before administering a blood transfusion. While obtaining consent is the provider’s responsibility, the nurse can witness the signing and ensure that the client understands the procedure.

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A nurse is reinforcing discharge teaching with a client who has heart failure. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is C

Explanation

The nurse is reviewing the client's medical record. Exhibits The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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