A client who follows Mormon beliefs is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply.

Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.

Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.

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.