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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3.

Exhibits

Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.

"I will restrict my fluid intake to less than 1 L per day."

"It is important to check my blood pressure at different times of the day."

“I understand that I need to restrict potassium in my diet."

“I will check my weight first thing in the morning”

“I will notify my provider if suddenly notice weight gain."

“I only need to check my weight weekly.”

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:

A. "I will restrict my fluid intake to less than 1 L per day." Fluid restriction to less than 1L/day is excessive and unnecessary unless the client has severe fluid retention. The client should follow specific instructions from their healthcare provider regarding fluid intake.

B. "It is important to check my blood pressure at different times of the day." This shows understanding of blood pressure fluctuations. Regular monitoring, especially in those with kidney dysfunction, is important to detect abnormal increases.

C. "I understand that I need to restrict potassium in my diet." Impaired renal function can lead to impaired potassium excretion causing hyperkalemia. Potassium restriction helps prevent cardiac complications from elevated potassium levels.

D. "I will check my weight first thing in the morning." Weighing in the morning gives a consistent baseline to track sudden weight changes, which can indicate fluid retention or worsening kidney function.

E. "I will notify my provider if I suddenly notice weight gain." Rapid weight gain can indicate fluid retention or worsening kidney function. The client should inform their provider if this occurs to prevent complications.

F. "I only need to check my weight weekly." Daily weight monitoring is more appropriate for clients with kidney or heart conditions to detect sudden fluid retention. Weekly checks may miss early signs of fluid retention.

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Correct Answer is B

Explanation

Rationale:

A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.

B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.

C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.

D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.

A. "Remove the needle from the syringe before you place it in the trash." B. "Secure the cap tightly over the needle before you discard it" C. "Place your storage container in a recycle bin when it is full." D. "You can discard needles in an empty bleach bottle with a lid."

Correct Answer is D

Explanation

Rationale:

A. "Remove the needle from the syringe before you place it in the trash." Needles should not be removed from syringes before disposal. This can increase the risk of needle-stick injuries. The entire syringe and needle should be disposed of intact in a proper sharps container.

B. "Secure the cap tightly over the needle before you discard it" Securing the cap over the needle increases the risk of needle-stick injuries. The needle should be placed directly in a sharps container without recapping.

C. "Place your storage container in a recycle bin when it is full." Sharps containers should never be placed in a recycle bin due to the risk of injury. Once full, the sharps container should be disposed of in a designated waste disposal service.

D. "You can discard needles in an empty bleach bottle with a lid.” The nurse should instruct the client to dispose of used needles in a rigid, puncture-proof container, such as an empty bleach bottle with a secure lid, until a proper sharps container is available. This helps prevent injury to others.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3. Exhibits Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0730 on Day 3.

Exhibits

Which of the following statements by the client indicates understanding of the discharge instruction?Select all that Apply.