A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Weigh every morning.

Perform range of motion exercises.

Limit fluid intake to 1,500 mL daily.

Eat a high protein diet.

Answer and Explanation

The Correct Answer is A

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

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Correct Answer is ["B","C","D"]

Explanation

A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

A. Hematocrit. B. Platelet count. C. Creatinine level. D. White blood cell (WBC) count.

Correct Answer is D

Explanation

The presence of purulent drainage at the wound indicates a potential infection, and monitoring the client's WBC count is an important laboratory value to assess for signs of infection. An elevated WBC count, specifically an increase in the neutrophil count (neutrophilia), can indicate an active infection and provide important information for the healthcare provider when evaluating the wound.

While hematocrit, platelet count, and creatinine level are essential laboratory values to assess the client's overall condition, they may not provide specific information regarding the presence of infection or purulent drainage at the wound site.

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A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

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Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is D

Explanation

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