A nurse is reinforcing discharge teaching with a client who has heart failure. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Alternate activity and rest.
Reduce sodium intake to 2 g per day.
Consume a low-fiber diet.
Gradually increase activity each day.
Eat small, frequent meals each day.
Correct Answer : A,B,D,E
A. Alternate activity and rest. Clients with heart failure should balance activity and rest to prevent overexertion and minimize cardiac workload. Frequent rest periods help conserve energy and reduce symptoms such as dyspnea and fatigue.
B. Reduce sodium intake to 2 g per day. Limiting sodium intake helps prevent fluid retention and reduces the risk of worsening heart failure. Excess sodium contributes to increased blood volume and exacerbates symptoms such as edema and shortness of breath.
C. Consume a low-fiber diet. A low-fiber diet is not necessary for heart failure management. Adequate fiber intake is beneficial for preventing constipation, which can increase strain during bowel movements and lead to hemodynamic stress. A high-fiber diet is generally encouraged.
D. Gradually increase activity each day. Clients should slowly increase their activity level based on tolerance to improve cardiovascular function. Overexertion should be avoided, but regular, controlled exercise helps maintain mobility and enhance overall heart health.
E. Eat small, frequent meals each day. Eating smaller meals reduces gastric distension and minimizes pressure on the diaphragm, which can help alleviate shortness of breath. Large meals can increase metabolic demands and contribute to discomfort in clients with heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pivotal Joint (Radius-Ulnar Joint) –A pivot joint allows for rotation around a single axis. The joint between the radius and ulna at the elbow allows the forearm to rotate (pronation/supination). This is not a ball-and-socket joint because it does not allow movement in multiple planes.
B. A ball-and-socket joint allows for the greatest range of motion in multiple directions, including flexion, extension, abduction, adduction, and rotation. Examples are the hip joint (femur-acetabulum) and shoulder joint (humerus-glenoid cavity).
C. A hinge joint allows movement in only one plane (like a door hinge) with flexion and extension. Examples are the knee joint (tibia-femur) and elbow joint (humerus-ulna) function as hinge joints. It is not a ball-and-socket joint because it does not allow rotation or movement in multiple planes.
D. A condyloid (ellipsoidal) joint allows movement in two planes (flexion/extension and abduction/adduction), but no rotation. Examples are the wrist joint (radiocarpal joint) allows side-to-side and up-and-down movements but lacks full rotation.
Correct Answer is B
Explanation
A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.
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