Exhibits

Select the 2 actions the nurse should prepare to take for the client.

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.

A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.