The nurse is caring for a patient with heart failure. Which of the following treatment goals should the nurse prioritize?
Administer high-calorie diet to prevent weight loss.
Reduce sodium intake to help manage fluid retention.
Encourage complete bed rest to reduce cardiac workload.
Increase fluid intake to maintain hydration.
The Correct Answer is B
A. Administer high-calorie diet to prevent weight loss. While adequate nutrition is important, a high-calorie diet is not the primary priority in managing heart failure. Sodium and fluid management are usually more crucial to control fluid overload.
B. Reduce sodium intake to help manage fluid retention. Reducing sodium intake is a priority in heart failure management as it helps prevent fluid retention, which reduces workload on the heart and decreases symptoms of fluid overload.
C. Encourage complete bed rest to reduce cardiac workload. Complete bed rest is not recommended as it can lead to deconditioning and increased risk of blood clots. Activity should be balanced according to the patient’s tolerance.
D. Increase fluid intake to maintain hydration. In heart failure, increasing fluid intake could worsen fluid overload. Fluid restriction may be necessary to prevent excess fluid retention.
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Correct Answer is B
Explanation
A. High fluid intake: High fluid intake can help maintain blood flow and reduce the risk of venous stasis.
B. Immobility during and after surgery: Immobility contributes to venous stasis and is a primary risk factor for DVT, especially after prolonged surgery.
C. Low body temperature: Low body temperature does not directly cause venous stasis or increase the risk of DVT.
D. Increased physical activity: Increased physical activity promotes circulation and reduces the risk of DVT by preventing blood from pooling in the veins.
Correct Answer is B
Explanation
A. The gallbladder became infected by a virus and needs to be removed. Gallstones are not caused by viral infections; they typically develop from an imbalance in the substances that make up bile, such as cholesterol and bilirubin.
B. The gallbladder has become inflamed due to the cholesterol in the gallstones. Cholesterol is a common component of gallstones, and these stones can cause inflammation of the gallbladder (cholecystitis), leading to the need for removal.
C. The gallbladder has become blocked by a tumor and is no longer working. Tumors can obstruct the gallbladder, but this is not the cause of gallstones or the primary reason for a cholecystectomy.
D. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct. This describes choledocholithiasis, a condition where gallstones block the common bile duct, but it is not the primary cause of gallbladder inflammation requiring a cholecystectomy.