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Which electrolyte imbalance is a common concern for patients on loop diuretics?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A, Hypokalemia. Loop diuretics can lead to potassium loss, resulting in hypokalemia. This imbalance is a common concern because potassium plays a vital role in various physiological functions, including maintaining proper heart function. Choices B, C, and D are incorrect because loop diuretics typically do not cause hyperkalemia, hyponatremia, or hypercalcemia.
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How should fluid balance be assessed in a patient with heart failure?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Monitor blood pressure
Correct Answer: A
Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.
A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?
- A. Limit the client's sodium intake to 4 grams per day.
- B. Measure the client's abdominal girth daily.
- C. Monitor the client's urine specific gravity every 12 hours.
- D. Encourage the client to drink 3 liters of fluid per day.
Correct Answer: B
Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.
A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Increased appetite
- B. Dry mucous membranes
- C. Hypotension
- D. Hyperreflexia
Correct Answer: C
Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.
A nurse is providing discharge teaching to a client who is postoperative following a mastectomy. Which of the following instructions should the nurse include?
- A. Avoid using deodorant until the incision heals.
- B. Perform arm exercises 24 hours after surgery.
- C. Wear tight-fitting clothing to support the incision.
- D. Perform arm exercises 2 days after surgery.
Correct Answer: A
Rationale: The correct instruction for the nurse to include is to advise the client to avoid using deodorant until the incision heals. Using deodorant can lead to skin irritation, which should be prevented following a mastectomy. Choice B is incorrect because performing arm exercises should typically be delayed until recommended by the healthcare provider to prevent strain on the surgical site. Choice C is incorrect as tight-fitting clothing can increase discomfort and hinder proper healing. Choice D is also incorrect because initiating arm exercises should be based on the healthcare provider's guidance and not a specific timeframe.
A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing. Which of the following foods should the nurse recommend?
- A. Bananas
- B. Fish
- C. White bread
- D. Chicken breast
Correct Answer: D
Rationale: Corrected Rationale: Chicken breast is an excellent source of protein, which is essential for wound healing due to its role in tissue repair and regeneration. Fish is also a good source of protein, but chicken breast is a more commonly recommended option for wound healing due to its high protein content and lower fat content compared to some types of fish. Bananas and white bread, on the other hand, are not high-protein foods and do not provide the necessary nutrients for wound healing.