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. Administering pain medication: Pain management is essential, but in this case, the primary concern is potential airway compromise due to inhalation injury, which should be addressed first.
B. Applying a cool, wet cloth to burned areas: Cooling burned areas can help with pain and reduce burn severity but is not the priority in a case of suspected inhalation injury with airway compromise.
C. Administering high-flow oxygen via a non-rebreather mask: This client is at high risk for respiratory compromise due to inhalation injury; administering high-flow oxygen is the priority to ensure adequate oxygenation.
D. Initiating intravenous fluid resuscitation: Fluid resuscitation is essential for burn patients but is not the immediate priority over addressing potential airway and oxygenation issues.
Correct Answer is C
Explanation
A. Share personal items like razors and toothbrushes. Sharing personal items that may come in contact with blood or body fluids, like razors and toothbrushes, increases the risk of spreading hepatitis, so clients should avoid sharing these items.
B. Drink alcohol in moderation to avoid liver strain. Clients with hepatitis should avoid alcohol entirely, as alcohol can worsen liver inflammation and damage, which would strain the liver further.
C. Wash your hands thoroughly after using the bathroom. Hand hygiene is crucial, especially for hepatitis A, which can spread through fecal-oral transmission. Washing hands can prevent the spread of the virus to others.
D. Avoid all physical activities to conserve energy. Although clients may need to rest, they do not need to avoid all physical activity. Light, tolerated activity can help maintain strength and prevent complications from immobility.