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 C
Explanation
A. Frequent urination: Frequent urination is not associated with osteomyelitis, a bone infection.
B. Increased range of motion: Osteomyelitis typically causes pain and restricted movement, not increased range of motion.
C. Localized bone pain and tenderness: Osteomyelitis commonly presents with localized bone pain, tenderness, and possibly swelling due to infection.
D. Hyperpigmentation of the skin: Hyperpigmentation is not a typical sign of osteomyelitis.
Correct Answer is A
Explanation
A. Reposition the client at least every two hours. Regular repositioning reduces prolonged pressure on specific areas of the body, which helps prevent the formation of pressure injuries.
B. Encourage the client to limit fluid intake. Adequate hydration is important for skin integrity. Limiting fluid intake could lead to dehydration, increasing the risk for skin breakdown.
C. Use a donut-shaped cushion under the client's hips. Donut-shaped cushions can actually increase pressure around the edges of the cushion and restrict blood flow, which could worsen pressure injury risk.
D. Apply a heating pad to the client's back every four hours. Heat can cause skin damage and may increase the risk of burns. Temperature regulation is important, but heating pads are not recommended for pressure injury prevention.