A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

Correct Answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

Correct Answer: C

Rationale: The correct answer is C) The medication must be continued so the fluid problem is controlled. Rationale: This response is the best because diuretics are essential in managing congestive heart failure by reducing fluid buildup in the body. Continual use of diuretics helps maintain optimal fluid balance and prevent complications associated with fluid retention, such as edema and shortness of breath. Option A is incorrect because the need for diuretics is based on the underlying condition, not solely on increased urination. Option B is incorrect as the duration of diuretic therapy varies depending on the individual's condition and should not be generalized. Option D is incorrect as it does not provide specific guidance on the importance of continuing diuretic therapy in managing congestive heart failure. In an educational context, understanding the rationale behind the importance of diuretic therapy in congestive heart failure management is crucial for nurses providing home care. Nurses must educate clients on the necessity of adhering to prescribed medications to effectively manage their condition and improve their quality of life.

Correct Answer: C

Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.

Correct Answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

Correct Answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.