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A client with a history of hypertension is being discharged on a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. I will use fresh herbs and spices instead of salt.
- B. I will avoid canned soups and processed foods.
- C. I can eat as much bacon and sausage as I want because they taste good.
- D. I will read food labels to check for sodium content.
Correct Answer: C
Rationale: Choice C is the correct answer because bacon and sausage are high in sodium, which contradicts the low-sodium diet requirement. Consuming them freely would contribute to increased sodium intake, which is not suitable for managing hypertension. Choices A, B, and D demonstrate appropriate understanding and actions for a low-sodium diet, such as using alternatives to salt, avoiding processed foods, and checking food labels for sodium content.
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The nurse is preparing a client for discharge after a myocardial infarction (MI). Which instruction is most important for the nurse to reinforce with the client?
- A. Avoid engaging in sexual activity for at least 6 weeks.
- B. Engage in moderate physical activity daily.
- C. Take prescribed medications even if you feel well.
- D. Return to work only when medically cleared.
Correct Answer: C
Rationale: The most critical instruction for a client after a myocardial infarction is to continue taking prescribed medications even if they feel well. This is essential in preventing another myocardial infarction or other complications. Discontinuing medications prematurely can be detrimental to the client's recovery and may increase the risk of further cardiovascular events. Choices A, B, and D are incorrect because engaging in sexual activity, physical activity, or returning to work are important aspects of the client's recovery, but not as crucial as ensuring medication compliance to prevent further cardiac issues.
The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving digoxin (Lanoxin). Which sign should the nurse monitor for that could indicate digoxin toxicity?
- A. Bradycardia
- B. Tachycardia
- C. Hypertension
- D. Hyperglycemia
Correct Answer: A
Rationale: Bradycardia is a common sign of digoxin toxicity and should be closely monitored. Digoxin toxicity can lead to various cardiac dysrhythmias, with bradycardia being a significant indicator. Monitoring the client's heart rate is crucial to detect and manage digoxin toxicity promptly. Tachycardia, hypertension, and hyperglycemia are not typically associated with digoxin toxicity. Tachycardia is more commonly seen with inadequate treatment of heart failure, hypertension is a possible but less common effect, and hyperglycemia is not a typical sign of digoxin toxicity.
The client is reinforcing instructions for a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. I will avoid adding salt to my food while cooking.
- B. I will use salt substitutes instead of regular salt.
- C. I can eat as much processed food as I like since it's usually low in sodium.
- D. I will read food labels to check for sodium content.
Correct Answer: C
Rationale: The correct answer is C. Processed foods often contain high amounts of sodium, so they should be limited or avoided on a low-sodium diet. Choosing processed foods can lead to increased sodium intake, counteracting the purpose of following a low-sodium diet. Option A shows an understanding of avoiding added salt, Option B suggests using alternatives to regular salt, and Option D indicates a willingness to check food labels for sodium content, all of which are appropriate for a low-sodium diet. Therefore, the client's statement about eating processed foods freely is incorrect and requires further teaching.
A client with a diagnosis of deep vein thrombosis (DVT) has been placed on bed rest. The LPN/LVN should reinforce which instruction to the client to prevent complications?
- A. Perform ankle pumps and circles every 1 to 2 hours.
- B. Use a heating pad to relieve pain in the affected leg.
- C. Keep the affected leg flat and avoid elevation.
- D. Wear tight compression stockings to prevent swelling.
Correct Answer: A
Rationale: Performing ankle pumps and circles every 1 to 2 hours is crucial for a client with DVT on bed rest. These exercises promote venous return, preventing stasis and reducing the risk of complications such as pulmonary embolism. Ankle pumps help activate the calf muscle pump, assisting in propelling blood back to the heart and preventing blood clots from forming or worsening. Choice B is incorrect because using a heating pad can increase blood flow to the area, potentially dislodging a clot. Choice C is incorrect because elevation helps reduce swelling and improve venous return. Choice D is incorrect because although compression stockings can be beneficial, they are not the most important instruction for preventing complications in this scenario.
A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?
- A. Take the medication in the morning.
- B. Increase potassium intake in the diet.
- C. Weigh yourself daily.
- D. Limit fluid intake to 2 liters per day.
Correct Answer: C
Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.