The nursing students are preparing a care plan for a patient with heart failure. The patient will be prescribed diuretic therapy after discharge. What evidence-based instructions will the nurse include in this plan?
Potassium supplements can cause irregular heart rhythm and must be avoided.
Instruct the patient to take diuretics at bedtime to promote diuresis during the night.
Notify the physician if weight increases by three pounds in one week.
Administer diuretics in the morning and notify physician of decreased urine output.
The Correct Answer is C
Choice A reason: Potassium supplements can actually be important for patients on diuretic therapy, especially if they are taking loop diuretics like furosemide, which can cause potassium loss. However, it is important to monitor potassium levels and follow the physician's guidance on supplement use.
Choice B reason: Instructing the patient to take diuretics at bedtime is not recommended. Diuretics should be taken in the morning to avoid frequent urination during the night, which can disrupt sleep.
Choice C reason: Notifying the physician if weight increases by three pounds in one week is a key instruction for patients with heart failure. Rapid weight gain can indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and adjustment of treatment.
Choice D reason: Administering diuretics in the morning and notifying the physician of decreased urine output is important, but the focus on notifying the physician about significant weight gain provides a more specific and actionable guideline for managing heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
Choice A reason: Eating any foods before dialysis as long as fluid intake is limited is incorrect. Patients undergoing hemodialysis need to follow specific dietary restrictions to manage electrolyte balance and prevent complications. A renal diet typically limits potassium, phosphorus, and sodium intake, in addition to fluid restrictions.
Choice B reason: Reporting any unusual changes in the access site, like redness or swelling, is correct. Changes at the access site can indicate infection or other complications and require immediate attention.
Choice C reason: Checking blood pressure regularly to monitor for changes during dialysis is correct. Blood pressure monitoring is essential during dialysis to detect hypotension or hypertension and adjust treatment accordingly.
Choice D reason: Contacting the healthcare provider if swelling in hands, feet, or ankles is noticed is correct. Swelling can indicate fluid overload or other complications that need to be addressed.
Choice E reason: Understanding that hemodialysis will permanently cure kidney disease is incorrect. Hemodialysis is a treatment that replaces kidney function but does not cure kidney disease. It manages symptoms and removes waste products from the blood.
Correct Answer is B
Explanation
Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.
Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.
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