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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
Choice B reason: Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
Choice C reason: Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
Correct Answer is C
Explanation
Choice A reason: Limiting high-calorie supplements to between meals is not a good strategy for managing anorexia while receiving radiation therapy because it can reduce the appetite and intake of regular meals, which are more nutritious and balanced. High-calorie supplements should be used as an addition to, not a replacement for, regular meals.
Choice B reason: Avoiding overeating during 'good' days is not a good strategy for managing anorexia while receiving radiation therapy because it can cause discomfort, nausea, or vomiting, which can worsen anorexia and affect the tolerance of radiation therapy. Eating should be based on hunger and satiety cues, not on good or bad days.
Choice C reason: Consuming nutrition-dense foods first is a good strategy for managing anorexia while receiving radiation therapy because it can ensure adequate intake of calories, protein, vitamins, and minerals, which are essential for healing and recovery. Nutrition-dense foods are those that provide high amounts of nutrients per serving, such as eggs, cheese, nuts, beans, and meat.
Choice D reason: Eating hot foods rather than cold foods is not a good strategy for managing anorexia while receiving radiation therapy because it can irritate the mouth and throat, which may be inflamed or sore due to radiation therapy. Cold foods are more soothing and refreshing for the mouth and throat, such as ice cream, yogurt, smoothies, and popsicles.
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