NCLEX-PN

Category - Basic Care

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A client with congestive heart failure is admitted to the facility after complaining of shortness of breath. The nurse caring for the client should expect which order when the client gains 2 pounds in one day?

Offer foods low in potassium
Restrict fluid intake
Limit caloric intake
Increase intake of foods high in sodium

Explanation

Answer: B - A client who gained more than 2 pounds in 24 hours is likely suffering from fluid retention, so the nurse should prepare to restrict the fluid intake of client, as ordered. Foods high in sodium must be avoided as it can further retain fluids. The other options are not appropriate.

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