The LPN/LVN is assisting in the care of a client with chronic heart failure who is receiving furosemide (Lasix). Which instruction should the nurse reinforce with the client?
- A. Limit your fluid intake to avoid fluid overload.
- B. Increase your potassium intake by eating bananas and oranges.
- C. Weigh yourself once a week to monitor for fluid retention.
- D. Take the medication at night to avoid frequent urination during the day.
Correct Answer: B
Rationale: The correct instruction for the nurse to reinforce with the client is to increase potassium intake by eating bananas and oranges. Furosemide can lead to potassium loss, potentially causing hypokalemia. By increasing potassium intake through diet, the client can help prevent this electrolyte imbalance and maintain overall health.
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The healthcare professional is caring for a client who has just returned from a cardiac catheterization. The healthcare professional should prioritize which assessment?
- A. Monitoring the client's vital signs every 4 hours
- B. Assessing the puncture site for bleeding
- C. Encouraging the client to ambulate early to prevent complications
- D. Providing the client with fluids to flush out the contrast dye
Correct Answer: B
Rationale: Assessing the puncture site for bleeding is a critical assessment after a cardiac catheterization procedure. This is essential to detect and address any potential complications promptly, such as hemorrhage or hematoma formation. Monitoring the puncture site helps ensure early intervention and prevent further complications, making it the priority assessment in this situation.
The nurse is caring for a client who has undergone a coronary artery bypass graft (CABG) surgery. Which action should the nurse take to prevent postoperative complications?
- A. Encourage the client to cough and deep breathe every 1 to 2 hours.
- B. Maintain the client in a supine position at all times.
- C. Keep the client on bed rest for the first 48 hours.
- D. Restrict the client's fluid intake to prevent overload.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client has a new prescription for rifampin. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Expect red-orange discoloration of body fluids.
- C. Monitor for signs of hyperglycemia.
- D. Avoid consuming dairy products.
Correct Answer: B
Rationale: The correct answer is to inform the client to expect red-orange discoloration of body fluids when taking rifampin. This side effect is harmless but can be surprising to patients. It is important for the nurse to educate the client about this expected change to prevent unnecessary concern or alarm. Monitoring for hyperglycemia is not directly related to rifampin, and taking the medication with food or avoiding dairy products are not specific instructions for this medication.
A client with a diagnosis of hypertension is prescribed atenolol (Tenormin). The nurse should monitor the client for which common side effect of this medication?
- A. Tachycardia
- B. Dry mouth
- C. Hypotension
- D. Increased appetite
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a client receiving anticoagulant therapy. Which instruction should the nurse reinforce with the client to prevent bleeding complications?
- A. Use a soft-bristle toothbrush and electric razor.
- B. Increase your intake of vitamin K-rich foods.
- C. Take aspirin if you have a headache.
- D. Avoid using ice packs for injuries.
Correct Answer: A
Rationale: The correct instruction to prevent bleeding complications in a client on anticoagulant therapy is to use a soft-bristle toothbrush and electric razor. These implements help reduce the risk of bleeding by being gentle on the skin and reducing the chances of cuts or abrasions that could lead to bleeding in individuals on anticoagulants.