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The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
- A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
- B. Increase fluid intake to stay hydrated
- C. Consume a high-sodium diet to retain fluids
- D. Engage in vigorous exercise daily
Correct Answer: A
Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.
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An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?
- A. Capillary refill takes > 3 seconds.
- B. Episodes of vertigo and loss of balance.
- C. Average daily output of 1200 ml.
- D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
- A. Increase intake of high-fiber foods, such as bran cereal
- B. Restrict protein intake by limiting meats and other high-protein foods.
- C. Limit oral fluid intake to 500ml per day
- D. Increase intake of potassium-rich foods such as bananas and cantaloupe.
Correct Answer: B
Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
- A. Review the client's dietary intake of high protein foods
- B. Notify the healthcare provider of the finding immediately
- C. Discuss approaches to chronic pain control with the client
- D. Assess the client's radial pulses and capillary refill time
Correct Answer: C
Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct Answer: A
Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.
A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?
- A. Ensure patency of an indwelling catheter and measure hourly intake and output.
- B. Prepare for cessation of the anesthesia and the surgical procedure.
- C. Obtain specimens of ABGs and serum electrolytes.
- D. Initiate cooling measures using iced normal saline by nasogastric lavage.
Correct Answer: B
Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.