A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select all that apply.)

Limit intake of canned soups.

Choose botled salad dressings.

Choose diet sodas over botled water.

Replace processed meats with fresh meat products.

Read labels on foods before eating.

Answer and Explanation

Correct Answer : A,D,E

Choice A: Limit intake of canned soups is correct because canned soups are high in sodium and can increase blood
pressure and ﬂuid retention. The nurse should advise the client to choose low-sodium or homemade soups instead.

Choice B: Choose botled salad dressings is incorrect because botled salad dressings are also high in sodium and can have added sugars and fats. The nurse should advise the client to make their own salad dressings with vinegar, oil, herbs, and spices.

Choice C: Choose diet sodas over botled water is incorrect because diet sodas are not a healthy alternative to water. Diet sodas contain artificial sweeteners, caﬀeine, and phosphoric acid, which can aﬀect the body's pH balance and calcium absorption. The nurse should advise the client to drink plain water or ﬂavored water with natural ingredients.

Choice D: Replace processed meats with fresh meat products is correct because processed meats such as bacon, ham, sausage, and hot dogs are high in sodium and preservatives. The nurse should advise the client to choose fresh meat products such as chicken, turkey, fish, or lean beef.

Choice E: Read labels on foods before eating is correct because reading labels can help the client identify the sodium content and other ingredients in foods. The nurse should advise the client to look for foods that have less than 140 mg of sodium per serving and avoid foods that have salt, sodium, or monosodium glutamate (MSG) in the ingredient list.

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Correct Answer is B

Explanation

Choice A: Concentrated hemoglobin and hematocrit levels are not a sign of ﬂuid volume overload, but rather of ﬂuid volume deficit. This is a condition that occurs when the body loses more ﬂuid than it gains. This can happen in patients who have excessive bleeding, vomiting, diarrhea, or diaphoresis. Concentrated hemoglobin and hematocrit levels indicate hemoconcentration, which is an increase in the ratio of blood cells to plasma.

Choice B: Distended neck veins are a sign of ﬂuid volume overload, because this condition occurs when the body retains more ﬂuid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive ﬂuid intake. Distended neck veins indicate increased central venous pressure, which is a measure of the pressure in the right atrium of the heart.

Choice C: Decreased urine output is not a sign of ﬂuid volume overload, but rather of oliguria or anuria. These are conditions that occur when the urine output is less than 400 mL or 50 mL per day, respectively. These can happen in patients who have acute or chronic kidney injury, urinary obstruction, or shock. Decreased urine output indicates impaired renal function and decreased glomerular filtration rate.

Choice D: Poor skin turgor is not a sign of ﬂuid volume overload, but rather of dehydration. This is a condition that occurs when the body loses more water than it gains. This can happen in patients who have fever, diabetes insipidus, or hyperglycemia. Poor skin turgor indicates decreased skin elasticity and delayed return to normal shape after being pinched.

A. Kussmaul respirations B. Cold, clammy skin C. Dysrhythmias D. Tachycardia E. Weakness

Correct Answer is ["A","C","D","E"]

Explanation

Choice A: Kussmaul respirations are a sign of metabolic acidosis, which is a condition that occurs when the body produces too much acid or loses too much bicarbonate. This can happen in patients with diabetes mellitus who develop diabetic ketoacidosis (DKA), a serious complication that results from insufficient insulin and high blood glucose levels. Kussmaul respirations are deep, rapid, and labored breathing that helps to eliminate excess carbon dioxide and acid from the blood.

Choice B: Cold, clammy skin is not a sign of metabolic acidosis, but rather of hypoglycemia, which is a condition that occurs when the blood glucose level is too low. This can happen in patients with diabetes mellitus who take too much insulin or oral hypoglycemic agents, skip meals, or exercise excessively. Cold, clammy skin is caused by vasoconstriction and sweating that occur as the body tries to increase blood glucose levels.

Choice C: Dysrhythmias are a sign of metabolic acidosis, because acidosis aﬀects the electrical activity of the heart and can cause irregular heartbeats. Dysrhythmias can also result from electrolyte imbalances, such as hyperkalemia, which is a condition that occurs when the blood potassium level is too high. This can happen in patients with metabolic acidosis who have impaired renal function and cannot excrete excess potassium.

Choice D: Tachycardia is a sign of metabolic acidosis, because acidosis stimulates the sympathetic nervous system and increases the heart rate. Tachycardia can also result from dehydration, which is a common complication of DKA due to excessive ﬂuid loss from vomiting, diarrhea, and polyuria.

Choice E: Weakness is a sign of metabolic acidosis because acidosis reduces the availability of oxygen and nutrients to the tissues and muscles. Weakness can also result from hypovolemia, which is a condition that occurs when the blood volume is too low. This can happen in patients with metabolic acidosis who have severe ﬂuid loss and hypotension.

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A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select all that apply.)

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A postoperative patient is diagnosed with ﬂuid volume overload. What should the nurse expect to assess in this patient?

Correct Answer is B

Explanation

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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