During a teaching session on dietary management for heart failure, a client makes a statement. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: C

Rationale: The correct answer is C because decreasing fluid intake is essential in managing fluid retention and symptoms of heart failure. Restricting fluids helps prevent excessive fluid buildup in the body, thus reducing the workload on the heart and alleviating symptoms like swelling and shortness of breath. Choices A, B, and D are incorrect. Increasing intake of foods high in sodium can exacerbate fluid retention and worsen heart failure symptoms. Increasing potassium-rich foods is beneficial for some heart conditions but not heart failure specifically. Decreasing fiber intake is not a standard recommendation for heart failure management.

Correct Answer: A

Rationale: Including 9:00 AM Friday urine e.g., pre-start skew 24-hour totals (9 AM Friday to 9 AM Saturday); it's discarded. Discarding start, including end, and preserving are correct. Nurses need debriefing here e.g., timing for accurate collection, per lab standards.

Correct Answer: A

Rationale: The correct answer is A: 'I should increase my intake of foods high in iron.' Iron-deficiency anemia is managed by increasing the consumption of iron-rich foods to improve iron levels in the body. Foods high in iron include red meat, poultry, fish, beans, lentils, and iron-fortified cereals. Choices B, C, and D are incorrect because decreasing intake of iron-rich foods or increasing intake of calcium-rich foods would not address the deficiency in iron levels that characterizes iron-deficiency anemia.

Correct Answer: A

Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.

Correct Answer: A

Rationale: Early morning urine first void e.g., concentrated is best for urinalysis/C&S, detecting glucose, bacteria. Later dilutes; midnight, pre-breakfast vary. Nurses collect e.g., 6 AM for accuracy, per protocols.

Correct Answer: D

Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.

Correct Answer: C

Rationale: Supine position most suppresses respiration post-surgery by limiting diaphragm movement, unlike Fowler's, prone, or side-lying. Nurses adjust this to aid breathing.

Correct Answer: C

Rationale: The correct answer is C. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended for managing hypertension. Increasing the intake of fruits and vegetables is a key component of the DASH diet as these foods are rich in nutrients that can help lower blood pressure levels. Choices A, B, and D are incorrect because they go against the principles of the DASH diet, which focuses on reducing sodium intake, increasing potassium-rich foods, and consuming whole grains.

Correct Answer: D

Rationale: Subjective data are clients' perceptions e.g., 'I feel dizzy' reported directly, capturing experiences unmeasurable by others. This contrasts with objective data (e.g., pulse), observable by nurses. Observational recordings are objective, like noting pallor, not perceptions. Ancillary reports (e.g., lab results) are objective, external data, not client-voiced. Subjective data's focus on personal input e.g., pain severity enriches assessment, guiding nurses to explore symptoms' impact (e.g., anxiety's role), making it vital for holistic care and the correct classification here.