Nokea
A client with a history of a heart failure is receiving Furosemide (Lasix). The nurse should monitor the client for:
- A. Hypokalemia
- B. Hyperglycemia
- C. Hypertension
- D. Weight gain
Correct Answer: A
Rationale: Furosemide, a loop diuretic, causes potassium loss, risking hypokalemia, requiring monitoring. Hyperglycemia, hypertension, and weight gain are not primary concerns.
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A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse interpret the effectiveness of the instruction about diet and weight control?
- A. She is compliant with her diet as previously taught.
- B. She needs further instruction and reinforcement.
- C. She needs to increase her caloric intake.
- D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Rationale: She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. Restrictive dieting is not recommended during pregnancy.
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. If you forget to take your morning dose, double the night time dose.'
- B. You should take aspirin instead of acetaminophen (Tylenol) for headaches.'
- C. Carry a medications alert card with you at all times.'
- D. You should use a straight-edge razor when shaving your arms and legs.'
Correct Answer: C
Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
- A. Pork chop, baked acorn squash, brussel sprouts
- B. Chicken breast, rice, and green beans
- C. Roast beef, baked potato, and diced carrots
- D. Tuna casserole, noodles, and spinach
Correct Answer: A
Rationale: Acorn squash and brussels sprouts are potassium-rich, indicating successful teaching. The other options contain fewer potassium-rich foods.
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Nutritional status
- B. Impaired thinking
- C. Possible harm to self
- D. Rest and activity impairment
Correct Answer: C
Rationale: Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
The nurse is providing dietary teaching for a client with hypertension. Which food should be avoided by the client on a sodium-restricted diet?
- A. Dried beans
- B. Swiss cheese
- C. Peanut butter
- D. Colby cheese
Correct Answer: D
Rationale: Colby cheese is high in sodium, which should be avoided on a sodium-restricted diet to manage hypertension, unlike the other options, which are lower in sodium.