A nurse is assisting with the plan of care for a client who has heart failure. Which of the following interventions should the nurse recommend?
Offer snacks that are high in sodium.
Place the head of the client's bed flat.
Monitor the client's weight once per week.
Provide rest periods throughout the day.
The Correct Answer is D
A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.
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Related Questions
Correct Answer is B
Explanation
A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.
Correct Answer is A
Explanation
A. "I should use my wrist to test the temperature of the water before bathing": This is correct as using the wrist to test water temperature helps prevent burns or injuries, which is crucial for individuals with diabetes who may have reduced sensation in their feet.
B. "I should put lotion between my toes every day to prevent dryness and cracking": This is incorrect because applying lotion between the toes can promote fungal infections. Lotion should be applied to the tops and soles of the feet, avoiding the spaces between the toes.
C. "I should apply a heating pad to my feet every night to help with circulation": This is incorrect as heating pads can cause burns due to decreased sensation. It is safer to avoid direct heat applications.
D. "I should round the corners of my toenails with a nail file to prevent ingrown nails": This is incorrect; toenails should be trimmed straight across to prevent ingrown nails rather than rounded.
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