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 D
Explanation
Choice A reason: Gelatin is an incomplete protein, meaning it does not contain all nine essential amino acids that the body cannot synthesize.
Choice B reason: Legumes are incomplete proteins, but they can be combined with grains, nuts, seeds, or dairy products to form complete proteins.
Choice C reason: Almonds are incomplete proteins, but they can be combined with other foods to form complete proteins.
Choice D reason: Salmon is a complete protein, meaning it contains all nine essential amino acids that the body needs.
Correct Answer is C
Explanation
Choice A reason: Providing a snack 30 min before treatments can worsen nausea and diarrhea, as food can stimulate gastric motility and secretion. It is better to avoid eating for at least 2 hours before and after treatments.
Choice B reason: Ensuring foods are served hot can increase nausea and diarrhea, as hot foods can have strong smells and irritate the digestive tract. It is better to serve foods at room temperature or cold.
Choice C reason: Administering antiemetics on a schedule can prevent nausea and vomiting, which can lead to dehydration and electrolyte imbalance. Antiemetics can also reduce abdominal cramps and spasms that cause diarrhea.
Choice D reason: Serving low carbohydrate meals can aggravate diarrhea, as carbohydrates are the main source of energy for the body. It is better to serve high carbohydrate meals that are easy to digest, such as rice, potatoes, bread, or crackers.
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