a client with heart failure is prescribed a low sodium diet the nurse notices the clients meal tray contains high sodium foods what action should the
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Nursing Elites

HESI LPN

Adult Health Exam 1

1. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.

2. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

3. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

4. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

5. A client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications. What should be emphasized?

Correct answer: D

Rationale: In managing GERD, dietary modifications play a significant role. Avoiding spicy and fatty foods helps reduce irritation, while eating small, frequent meals prevents overeating, which can trigger reflux. Avoiding meals before bedtime allows for better digestion and reduces the likelihood of acid reflux during the night. Therefore, all of the options (A, B, and C) are crucial in managing GERD symptoms, making choice D the correct answer.

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