A nurse is providing teaching to a client who has heart failure and a decreased cardiac output. Which of the following information should the nurse include in the teaching?
Restrict daily exercise
Encourage 3 large meals per day.
Limit dietary salt intake
Obtain weight once per week.
The Correct Answer is C
Rationale:
A. Restrict daily exercise: Clients with heart failure benefit from regular, moderate activity as tolerated to improve cardiac efficiency and prevent deconditioning. Restricting all exercise can worsen functional status and is not recommended unless specifically limited by the healthcare provider.
B. Encourage 3 large meals per day: Large meals can increase cardiac workload and exacerbate heart failure symptoms due to increased blood flow demands during digestion. Smaller, more frequent meals are preferable to reduce strain on the heart.
C. Limit dietary salt intake: Reducing sodium intake helps prevent fluid retention and edema, which can exacerbate heart failure and increase cardiac workload. Teaching clients to limit salt is a key intervention to manage decreased cardiac output and maintain stable fluid balance.
D. Obtain weight once per week: Daily weight monitoring is recommended for clients with heart failure to detect fluid retention early. Weekly weights may delay recognition of sudden fluid accumulation, increasing the risk of decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Insert a large-bore IV catheter: A large-bore (18–20 gauge) IV catheter is required to allow rapid infusion of blood products if needed, minimizing hemolysis and ensuring adequate flow. This is critical for the safety and effectiveness of the transfusion, especially in clients who may be hemodynamically unstable.
B. Witness the client signing a consent for transfusion: Obtaining informed consent ensures the client understands the risks, benefits, and alternatives to the blood transfusion. Witnessing the signature is a legal and ethical requirement to confirm that the client has voluntarily agreed to the procedure.
C. Have a second nurse confirm the information on the blood label: Verification by a second nurse prevents administration errors, such as giving the wrong blood type or unit. This double-check process is essential for patient safety and is standard protocol before starting a transfusion.
D. Flush the transfusion tubing with dextrose 5 in water: Blood products should not be administered through tubing flushed with dextrose solutions because dextrose can cause red blood cell hemolysis. Normal saline is the only appropriate solution for priming and flushing blood administration tubing.
E. Explain to the client that transfusion reactions are not serious: Transfusion reactions can be life-threatening, including hemolytic, allergic, or febrile reactions. Minimizing the seriousness of these risks is inappropriate; the client should be informed about potential complications and instructed to report any symptoms immediately.
Correct Answer is D
Explanation
Rationale:
A. "The care team will discuss how to change the DNR prescription.": While discussions about code status may occur, the care team cannot override the client’s documented wishes. Focusing on changing the DNR for the family disregards the ethical and legal principle of patient autonomy.
B. "I will ask the client's provider to change the prescription.": The provider cannot unilaterally change a DNR order without the client’s consent. Doing so would violate the client’s legal rights and established advance directive.
C. "A family member can change a DNR prescription once it has been signed.": Only the client has the authority to modify or revoke a DNR unless the client is incapacitated and has legally designated a healthcare proxy. Family members do not have the right to override the client’s documented wishes arbitrarily.
D. "These are the client's wishes, and we must respect them.": The nurse’s response acknowledges the ethical and legal obligation to honor the client’s autonomy. DNR orders reflect the client’s informed decisions about life-sustaining treatments, which must be respected even if family members disagree.
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