The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Take the diuretic every day, regardless of weight loss or muscle weakness.

Weigh yourself daily at the same time and report excessive weight loss.

Limit fluid intake while taking the diuretic to reduce fluid retention.

Stop taking the medication when the edema in the lower extremities subsides.

Answer and Explanation

The Correct Answer is B

A.   Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B.   Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C.   Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D.   Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

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Correct Answer is C

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

A. Client's breath sounds are clear to auscultation bilaterally. B. Client exhibits a frequent productive cough. C. Client demonstrates proper use of an incentive spirometer. D. Client reports using the incentive spirometer every hour while awake.

Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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