A nurse is caring for a client who has heart failure and has gained 0.9 kg (2 lb) over the last 24 hr. Which of the following interventions should the nurse take?

Provide the client with three large meals per day.

Weigh the client once per week.

Reduce the client's sodium intake.

Restrict the client's protein intake.

Answer and Explanation

The Correct Answer is C

A.   Providing the client with three large meals per day may contribute to fluid retention and exacerbate heart failure symptoms. Smaller, more frequent meals may be better tolerated.
B.   Weighing the client once per week is not appropriate when there are signs of fluid retention and weight gain in a client with heart failure. More frequent monitoring of weight is necessary in this situation.
C.   Reducing the client's sodium intake can help decrease fluid retention and manage symptoms of heart failure. Excess sodium intake can lead to fluid retention and exacerbate heart failure symptoms.
D.   Restricting the client's protein intake is not indicated based solely on weight gain in heart failure. Protein restriction may lead to muscle wasting and compromise overall nutritional status.

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Correct Answer is ["A","C","E"]

Explanation

A. Olive oil and vinegar are healthier choices for salad dressing, especially for individuals with hypertension, as they are low in saturated fat and sodium.
B. This choice is incorrect because low-calorie does not necessarily mean low in sodium, which is crucial for managing hypertension.
C. Limiting processed cheese is advised because it often contains high levels of sodium, which can raise blood pressure.
D. This choice is incorrect as many frozen dinners are high in sodium and preservatives, which are not recommended for a hypertension-friendly diet.
E. Cooking pasta without salt is a good practice to reduce sodium intake, which is beneficial for blood pressure control.

A. Remove TPN from the refrigerator 5 min before infusing it. B. Change the dressing around the IV site weekly. C. Change the IV tubing for TPN solution every 72 hr. D. Discard remaining TPN solution that is still infusing after 24 hr.

Correct Answer is D

Explanation

Choice A Rationale: TPN should be removed from the refrigerator 30 minutes to an hour before use to allow it to reach room temperature, reducing the risk of crystallization and patient discomfort.

Choice B Rationale: The dressing around the IV site for TPN should be changed every 48 to 72 hours, not weekly, to prevent infection and ensure the integrity of the IV site.

Choice C Rationale: IV tubing for TPN solutions should be changed more frequently than every 72 hours, typically every 24 hours, to minimize the risk of bacterial contamination and infection.

Choice D Rationale: TPN solutions are at risk for bacterial growth, so any remaining solution after 24 hours should be discarded to prevent infection.

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A nurse is caring for a client who has heart failure and has gained 0.9 kg (2 lb) over the last 24 hr. Which of the following interventions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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