The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?
- A. Increase potassium-rich foods in the diet
- B. Avoid foods high in sodium
- C. Monitor fluid intake and adjust as needed
- D. Take the medication in the morning
Correct Answer: A
Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.
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The healthcare provider is assessing a client who has just undergone abdominal surgery. Which finding should be reported to the healthcare provider immediately?
- A. Absence of bowel sounds
- B. Mild abdominal distention
- C. Drainage of serosanguineous fluid from the incision
- D. Sudden onset of severe abdominal pain
Correct Answer: D
Rationale: Sudden onset of severe abdominal pain may indicate complications such as peritonitis, bowel perforation, or internal bleeding. These conditions are serious and require immediate medical attention to prevent further complications or deterioration. Absence of bowel sounds, mild abdominal distention, and drainage of serosanguineous fluid are common findings after abdominal surgery and may not necessarily indicate an emergency situation requiring immediate reporting to the healthcare provider. Severe abdominal pain post-surgery should always be reported promptly as it could signify a life-threatening situation that needs urgent evaluation and intervention.
Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)
- A. Heart rate
- B. Stroke volume
- C. Peripheral resistance
- D. Neuroendocrine hormones
Correct Answer: D
Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.
A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete.
- B. Take all prescribed medications as directed.
- C. Schedule a follow-up appointment with the healthcare provider.
- D. Wear a mask when in public places.
Correct Answer: B
Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.
The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct Answer: D
Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. What is the priority nursing intervention?
- A. Administer a high-flow oxygen mask.
- B. Position the client in a high-Fowler's position.
- C. Provide a high-carbohydrate diet.
- D. Encourage the client to cough and deep breathe.
Correct Answer: B
Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and breathing by reducing respiratory effort. Administering a high-flow oxygen mask (Choice A) may be necessary but is not the priority intervention. Providing a high-carbohydrate diet (Choice C) is not directly related to managing acute shortness of breath in COPD. Encouraging the client to cough and deep breathe (Choice D) is helpful for airway clearance but is not the priority intervention when the client is in distress with acute shortness of breath.
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