A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?

Set your goal body weight within 25% of your ideal body weight.

Limit alcohol consumption to two drinks a day for men and one drink a day for women when hypertensive.

Plan to lower sodium intake to less than 2,300 mg each day.

Plan to have potassium blood levels checked when taking thiazide diuretics.

None

Answer and Explanation

The Correct Answer is C

Choice A reason : Setting a goal body weight within 25% of the ideal body weight can be misleading. The ideal body weight should be determined based on body mass index (BMI), considering the individual's height and weight. A BMI of 18.5 to 24.9 is considered normal.

Choice B reason : This is a general guideline for alcohol consumption, but for individuals with hypertension, it is often recommended to limit alcohol intake even further to help manage blood pressure

Choice C reason : This is a key recommendation for managing hypertension. Reducing sodium intake helps lower blood pressure and is a widely accepted guideline

Choice D reason : Monitoring potassium levels is crucial when taking thiazide diuretics because these medications can decrease potassium levels in the blood, leading to hypokalemia.

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Correct Answer is D

Explanation

Choice A reason : Applying ice to the extremity is not a standard intervention for DVT. Ice is typically used to reduce inflammation and pain, but in the case of DVT, the priority is to prevent the clot from growing and embolizing. The use of warmth, not cold, may be recommended to help reduce discomfort and swelling.

Choice B reason : Administering vasodilating medications is not a typical intervention for DVT. Vasodilators are used to widen blood vessels and improve blood flow, but they do not address the risk of clot formation or embolization associated with DVT. The mainstay of medical treatment for DVT is anticoagulant therapy, which helps to prevent further clotting.

Choice C reason : Restricting oral fluids is not an intervention for DVT. Adequate hydration is important in the management of DVT as it can help to prevent blood from thickening and reduce the risk of further clot formation. There is no indication to restrict fluids unless there is another underlying condition that requires it.

Choice D reason : Monitoring platelet levels is an important intervention in the care of a client with DVT, especially if they are receiving anticoagulant therapy. Anticoagulants can affect platelet function and count, and monitoring is necessary to ensure safe levels and prevent complications such as bleeding or thrombocytopenia.

A. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate B. Obtain a 12-lead ECG C. Administer potassium gluconate 40 mEq orally D. Restrict fluid intake

Correct Answer is B

Explanation

Choice A reason : An erythrocyte sedimentation rate (ESR) test is not directly related to high serum potassium levels and would not be the immediate action in response to hyperkalemia.

Choice B reason : Obtaining a 12-lead ECG is a critical step when hyperkalemia is suspected because high potassium levels can cause life-threatening cardiac arrhythmias. An ECG can quickly reveal characteristic changes associated with hyperkalemia, allowing for prompt treatment.

Choice C reason : Administering potassium gluconate would be contraindicated in a patient with hyperkalemia, as it would further increase the serum potassium levels, potentially leading to severe complications.

Choice D reason : Restricting fluid intake is not a standard treatment for hyperkalemia. The management of hyperkalemia may include medications or procedures that promote the excretion of potassium or move potassium from the blood into the cells.

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A nurse is reinforcing teaching with a middle-aged client about hypertension. Which of the following information should the nurse include in the teaching?

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