A nurse is caring for a client who has heart failure and has gained 2 kg (4.4 lB. over the last 24 hours. Which of the following interventions should the nurse take?
Reduce the client's sodium intake.
Restrict the client's protein intake.
Weigh the client once per week.
Provide the client with three large meals per day.
The Correct Answer is A
Choice A reason: Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
Choice B reason: Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
Choice C reason: Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
Choice D reason: Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying ice packs for 15 minutes every hour is not an effective intervention for managing edema following knee replacement surgery because it can impair blood circulation and delay healing. Ice packs can also cause frostbite or nerve damage if applied for too long or too frequently. Ice packs should be used only for the first 24 to 48 hours after surgery and with a cloth barrier between the skin and the ice.
Choice B reason: Elevating the affected leg above the heart level is an effective intervention for managing edema following knee replacement surgery because it can reduce swelling and pain by facilitating venous return and lymphatic drainage. Elevation can also prevent blood clots and infection by improving blood flow and oxygen delivery to the wound site.
Choice C reason: Consuming nutrition-dense foods first is not a relevant intervention for managing edema following knee replacement surgery because it does not directly affect fluid balance or wound healing. Nutrition-dense foods are those that provide high amounts of nutrients per serving, such as eggs, cheese, nuts, beans, and meat. Nutrition-dense foods are important for overall health, but not specifically for edema management.
Choice D reason: Wearing compression stockings during the day is not a recommended intervention for managing edema following knee replacement surgery because it can interfere with wound healing and increase the risk of infection. Compression stockings can also cause skin irritation, blisters, or ulcers if worn incorrectly or too tightly. Compression stockings should be avoided until the wound is fully healed and only used under medical supervision.
Correct Answer is A
Explanation
Choice A reason: Alternating the first breast that is offered to the baby with each feeding can help ensure equal stimulation and drainage of both breasts, and prevent engorgement, mastitis, or milk supply problems.
Choice B reason: Storing breastmilk in the refrigerator up to 48 hours is not recommended, as it can reduce the quality and quantity of antibodies and nutrients in the milk. The optimal storage time for breastmilk in the refrigerator is up to 24 hours.
Choice C reason: Nursing the baby once every 4 hours is not sufficient, as it can lead to insufficient milk intake, dehydration, weight loss, or jaundice in the baby. The baby should be nursed on demand, or at least every 2 to 3 hours during the day and every 4 hours at night.
Choice D reason: Offering the baby water between feedings is not necessary, as it can interfere with breastfeeding and cause water intoxication or electrolyte imbalance in the baby. Breastmilk provides enough hydration and nutrition for the baby.
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