A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select all that apply.)
Limit intake of canned soups.
Choose botled salad dressings.
Choose diet sodas over botled water.
Replace processed meats with fresh meat products.
Read labels on foods before eating.
Correct Answer : A,D,E
Choice A: Limit intake of canned soups is correct because canned soups are high in sodium and can increase blood
pressure and fluid retention. The nurse should advise the client to choose low-sodium or homemade soups instead.
Choice B: Choose botled salad dressings is incorrect because botled salad dressings are also high in sodium and can have added sugars and fats. The nurse should advise the client to make their own salad dressings with vinegar, oil, herbs, and spices.
Choice C: Choose diet sodas over botled water is incorrect because diet sodas are not a healthy alternative to water. Diet sodas contain artificial sweeteners, caffeine, and phosphoric acid, which can affect the body's pH balance and calcium absorption. The nurse should advise the client to drink plain water or flavored water with natural ingredients.
Choice D: Replace processed meats with fresh meat products is correct because processed meats such as bacon, ham, sausage, and hot dogs are high in sodium and preservatives. The nurse should advise the client to choose fresh meat products such as chicken, turkey, fish, or lean beef.
Choice E: Read labels on foods before eating is correct because reading labels can help the client identify the sodium content and other ingredients in foods. The nurse should advise the client to look for foods that have less than 140 mg of sodium per serving and avoid foods that have salt, sodium, or monosodium glutamate (MSG) in the ingredient list.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: This is correct because using an infusion controller for the IV ensures that the KCL is delivered at a safe and accurate rate. KCL can cause cardiac arrest if infused too rapidly or in excess.
Choice B Reason: This is correct because adding the ordered dose to the IV bag hanging dilutes the KCL and reduces the risk of phlebitis and extravasation. KCL is irritating to the veins and can cause tissue damage if it leaks out of the vein.
Choice C Reason: This is correct because monitoring the injection site for redness can help detect signs of phlebitis and extravasation. The nurse should stop the infusion and notify the provider if these complications occur.
Choice D Reason: This is incorrect because monitoring fluid intake and output is not directly related to administering KCL. However, the nurse should monitor the patient's serum potassium level and renal function before and during KCL therapy, as kidney impairment can cause hyperkalemia.
Choice E Reason: This is incorrect because administering the dose IV push over 3 minutes is dangerous and contraindicated. KCL should never be given by IV push, bolus, or undiluted, as it can cause fatal cardiac arrhythmias.
Correct Answer is B
Explanation
Choice A: Sodium level is not a reliable measure of fluid retention because it can be affected by other factors such as diet, medication, and dehydration. Sodium level does not reflect the amount of water in the body.
Choice B: Daily weight is the most reliable measure of fluid retention because it reflects the changes in total body water. A weight gain of more than 0.5 kg (1 lb) in a day or 1.5 kg (3 lb) in a week indicates fluid retention.
Choice C: Intake and output is not a reliable measure of fluid retention because it does not account for insensible losses such as sweating, breathing, and fever. Intake and output can also be inaccurate due to measurement errors or incomplete records.
Choice D: Tissue turgor is not a reliable measure of fluid retention because it can be influenced by age, skin elasticity, and hydration status. Tissue turgor does not indicate the amount of fluid in the intravascular space.
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