A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess.
In planning nursing care, which interventions should the nurse include? Select all that apply.
Weigh the client daily, in the morning.
Teach the client how to restrict dietary sodium.
Monitor coagulation laboratory values.
Observe for evidence of hypokalemia.
Encourage an oral fluid intake of 3,000 mL/day.
Correct Answer : A,B,D
Choice A rationale
Weighing the client daily, in the morning, is an important intervention for a client with heart failure (HF) being treated with diuretics for fluid volume excess. Daily weights can help monitor the client’s fluid status and the effectiveness of the diuretic therapy.
Choice B rationale
Teaching the client how to restrict dietary sodium is an important intervention for a client with HF being treated with diuretics for fluid volume excess. A low-sodium diet can help prevent fluid retention and exacerbation of HF3.
Choice C rationale
Monitoring coagulation laboratory values is not typically necessary for a client with HF being treated with diuretics for fluid volume excess, unless the client is also receiving anticoagulant therapy.
Choice D rationale
Observing for evidence of hypokalemia is an important intervention for a client with HF being treated with diuretics for fluid volume excess. Diuretics can cause loss of potassium, which can lead to hypokalemia.
Choice E rationale
Encouraging an oral fluid intake of 3,000 mL/day is not typically recommended for a client with HF being treated with diuretics for fluid volume excess. Excessive fluid intake can exacerbate HF3.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Suggesting that the child participate in a team sport to encourage socialization is not the best response. Duchenne muscular dystrophy (DMD) is a progressive disease that causes muscle weakness and loss of muscle mass. Participating in a team sport could be physically challenging for the child and could potentially lead to injury.
Choice B rationale
Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the best response. Swimming is a low-impact exercise that can help maintain muscle strength and flexibility in children with DMD. It also provides an opportunity for socialization.
Choice C rationale
Explaining that the child is too young to understand the risks associated with swimming is not the best response. Children with DMD can participate in swimming with appropriate supervision and safety measures in place.
Choice D rationale
Providing a list of alternative activities that are less likely to cause the child to experience fatigue is not the best response. While it’s important to consider activities that are appropriate for the child’s physical abilities, it’s also important to consider the child’s interests. The child has expressed a desire to continue swimming, and with appropriate supervision, this activity can be beneficial.
Correct Answer is B
Explanation
Choice A rationale
Addiction refers to a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The intricate handwashing ritual that lasts two hours or more described by the client does not indicate substance use or dependency, which are common characteristics of addiction.
Choice B rationale
Compulsion refers to repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The client’s intricate handwashing ritual that lasts two hours or more and their concern about maintaining cleanliness align with the definition of a compulsion.
Choice C rationale
Obsession refers to recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and unwanted. While the client’s concern about maintaining cleanliness could potentially be seen as an obsession, the act of handwashing is a behavior, which aligns more with the definition of a compulsion.
Choice D rationale
Phobia refers to an extreme or irrational fear of or aversion to something. The client’s behavior does not indicate an extreme or irrational fear but rather a compulsion to maintain cleanliness through an intricate handwashing ritual.
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