Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has heart failure and has gained 2 kg (4.4 lB. over the last 24 hours. Which of the following interventions should the nurse take?
A. Reduce the client's sodium intake.
Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
B. Restrict the client's protein intake.
Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
C. Weigh the client once per week.
Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
D. Provide the client with three large meals per day.
Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nutrition 2019 Nexy Updated 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
Choice B reason: Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
Choice C reason: Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
Choice D reason: Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
Similar Questions
A nurse is caring for a client who has nausea following radiation therapy. Which of the following interventions is appropriate for the nurse to take?
A. Offer the client frozen banana as a snack.
Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help reduce nausea and stimulate appetite. Frozen banana is cold, bland, and easy to digest, which are characteristics of antiemetic foods. Frozen banana also provides potassium, vitamin C, and fiber for the client.
B. Serve the client hot meals.
Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
C. Avoid serving sauces or gravies.
Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
D. Discourage the use of a straw.
Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Full Explanation
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help reduce nausea and stimulate appetite. Frozen banana is cold, bland, and easy to digest, which are characteristics of antiemetic foods. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
A nurse is teaching about denture care to the partner of a client who is unable to perform oral hygiene. Which of the following points should the nurse include in the teaching?
A. Use a washcloth to clean the denture surfaces.
Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
B. Wipe dentures before storing them in a dry container at night.
Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
C. Floss dentures as part of daily cleaning.
Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
D. Wrap gloved fingers with gauze to remove dentures.
Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
Full Explanation
Choice A reason: Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
Choice B reason: Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
Choice C reason: Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
A nurse is caring for a client who is receiving parenteral nutrition and has a new prescription for probiotic therapy. Which of the following findings indicates that the therapy is effective?
A. Client reports ability to complete ADLs.
Reporting ability to complete ADLs is not a specific finding that indicates that probiotic therapy is effective. Ability to complete ADLs depends on various factors, such as energy level, muscle strength, mobility, cognition, and motivation. Ability to complete ADLs may improve with parenteral nutrition, but not necessarily with probiotic therapy.
B. Client's mucous membranes are pink.
Having pink mucous membranes is not a specific finding that indicates that probiotic therapy is effective. Pink mucous membranes reflect adequate hydration and oxygenation status, which are important for overall health, but not directly related to probiotic therapy.
C. Client's blood glucose level is within the expected reference range.
Having blood glucose level within the expected reference range is not a specific finding that indicates that probiotic therapy is effective. Blood glucose level is influenced by carbohydrate intake, insulin production, and medication use, which are related to parenteral nutrition, but not probiotic therapy.
D. Client has soft, formed bowel movements.
Having soft, formed bowel movements is a specific finding that indicates that probiotic therapy is effective. Probiotic therapy is the use of beneficial bacteria or yeast to restore the normal flora and function of the gastrointestinal tract, which can prevent or treat diarrhea, constipation, or infection. Having soft, formed bowel movements shows that the client has a healthy and balanced gut microbiome.
Full Explanation
Choice A reason: Reporting ability to complete ADLs is not a specific finding that indicates that probiotic therapy is effective. Ability to complete ADLs depends on various factors, such as energy level, muscle strength, mobility, cognition, and motivation. Ability to complete ADLs may improve with parenteral nutrition, but not necessarily with probiotic therapy.
Choice B reason: Having pink mucous membranes is not a specific finding that indicates that probiotic therapy is effective. Pink mucous membranes reflect adequate hydration and oxygenation status, which are important for overall health, but not directly related to probiotic therapy.
Choice C reason: Having blood glucose level within the expected reference range is not a specific finding that indicates that probiotic therapy is effective. Blood glucose level is influenced by carbohydrate intake, insulin production, and medication use, which are related to parenteral nutrition, but not probiotic therapy.
Choice D reason: Having soft, formed bowel movements is a specific finding that indicates that probiotic therapy is effective. Probiotic therapy is the use of beneficial bacteria or yeast to restore the normal flora and function of the gastrointestinal tract, which can prevent or treat diarrhea, constipation, or infection. Having soft, formed bowel movements shows that the client has a healthy and balanced gut microbiome.
