The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Take the diuretic every day, regardless of weight loss or muscle weakness.

Weigh yourself daily at the same time and report excessive weight loss.

Limit fluid intake while taking the diuretic to reduce fluid retention.

Stop taking the medication when the edema in the lower extremities subsides.

Answer and Explanation

The Correct Answer is B

A.   Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B.   Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C.   Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D.   Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

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Correct Answer is []

Explanation

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.

A. Initiate a referral for ophthalmic evaluation as soon as possible. B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve C. Instruct the client to rest, and report to the emergency department if eye pain develops. D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Correct Answer is A

Explanation

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