Nokea
The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself every day at the same time.
- B. I will call my doctor if my legs swell more.
- C. I will take my water pill only when I feel short of breath.
- D. I will limit the amount of salt in my diet.
Correct Answer: C
Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.
You may also like to solve these questions
A patient with stomatitis is receiving oral care education from a nurse. Which instructions will the nurse provide?
- A. Avoid commercial mouthwashes.
- B. Avoid normal saline rinses.
- C. Brush with a hard toothbrush.
- D. Brush with an alcohol-based toothpaste.
Correct Answer: A
Rationale: The correct instruction for a patient with stomatitis is to avoid commercial mouthwashes. Commercial mouthwashes often contain alcohol and other ingredients that can irritate the already inflamed oral mucosa in patients with stomatitis. Avoiding commercial mouthwashes helps prevent further irritation and discomfort. Choice B is incorrect because normal saline rinses are gentle and can help soothe the oral mucosa in patients with stomatitis. Choice C is incorrect because a soft toothbrush should be used to prevent further irritation or injury to the gums. Choice D is incorrect because an alcohol-based toothpaste can be too harsh and drying for patients with stomatitis.
What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct Answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.
The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?
- A. Assess surfaces exposed to the edges of the cast for pressure areas.
- B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
- C. Allow turning in bed to prevent complications.
- D. Encourage the patient's dietary intake to maintain hydration.
Correct Answer: A
Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
- A. Discontinue the machine and measure the blood pressure manually every 15 minutes.
- B. Adjust the machine settings.
- C. Clean the machine to ensure accuracy.
- D. Increase the frequency of the readings.
Correct Answer: B
Rationale: In this scenario, the nurse should adjust the machine settings. If the electronic blood pressure machine is providing varied intervals and inconsistent readings, it indicates a potential malfunction. Changing the settings may help correct the issue and ensure accurate measurements. Discontinuing the machine and measuring manually every 15 minutes (Choice A) may be time-consuming and impractical. Cleaning the machine (Choice C) is important for routine maintenance but may not address the current issue of varied intervals and inconsistent readings. Increasing the frequency of the readings (Choice D) does not address the problem of inaccurate measurements caused by the malfunctioning machine.
A client is grieving the loss of her partner and expresses thoughts of not seeing the point of living anymore. What action should the nurse take?
- A. Recommend that the client seek spiritual guidance
- B. Request additional support from the client's family
- C. Tell the client that this is a normal response to grief
- D. Ask the client if she plans to harm herself
Correct Answer: D
Rationale: When a client expresses feelings of hopelessness or worthlessness, it is crucial for the nurse to assess for suicidal ideation. Asking the client directly if she plans to harm herself is essential to determine the level of risk and ensure appropriate interventions are implemented. Recommending spiritual guidance (Choice A) may not address the immediate safety concerns related to suicidal ideation. Requesting additional support from the client's family (Choice B) is not as direct in addressing the client's safety. While stating that the client's response is a normal part of grief (Choice C) may provide validation, it does not address the potential risk of harm to the client.