A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess.
In planning nursing care, which interventions should the nurse include? Select all that apply.

Weigh the client daily, in the morning.

Teach the client how to restrict dietary sodium.

Monitor coagulation laboratory values.

Observe for evidence of hypokalemia.

Encourage an oral fluid intake of 3,000 mL/day.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale
Weighing the client daily, in the morning, is an important intervention for a client with heart failure (HF) being treated with diuretics for fluid volume excess. Daily weights can help monitor the client’s fluid status and the effectiveness of the diuretic therapy.
Choice B rationale
Teaching the client how to restrict dietary sodium is an important intervention for a client with HF being treated with diuretics for fluid volume excess. A low-sodium diet can help prevent fluid retention and exacerbation of HF3.
Choice C rationale
Monitoring coagulation laboratory values is not typically necessary for a client with HF being treated with diuretics for fluid volume excess, unless the client is also receiving anticoagulant therapy.
Choice D rationale
Observing for evidence of hypokalemia is an important intervention for a client with HF being treated with diuretics for fluid volume excess. Diuretics can cause loss of potassium, which can lead to hypokalemia.

Choice E rationale
Encouraging an oral fluid intake of 3,000 mL/day is not typically recommended for a client with HF being treated with diuretics for fluid volume excess. Excessive fluid intake can exacerbate HF3.

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale
Chills and fever are not typically associated with preeclampsia. They are more commonly seen in infections.
Choice B rationale
Lack of appetite is a non-specific symptom and can be associated with many conditions, but it is not a key indicator of preeclampsia.
Choice C rationale
Swollen hands can be a symptom of preeclampsia. This condition can cause sudden weight gain and swelling (edema), particularly in your face and hands.

Choice D rationale
Headaches are a common symptom of preeclampsia. They are often severe and may be accompanied by changes in vision.
Choice E rationale
Blurred vision is a symptom of preeclampsia. Other vision changes, such as sensitivity to light or temporary loss of vision, can also occur.
Choice F rationale
Frequent urination is not typically associated with preeclampsia. It is a common symptom in early and late pregnancy due to the growing uterus pressing on the bladder.

A. Perform a thorough physical assessment B. Develop a safety plan C. Take photographs to document the abuse or neglect D. Confront the abuser about concerning actions E. he client in front of the suspected abuser F. Complete a comprehensive history G. Throw away soiled clothing

Correct Answer is ["A","B","C","F"]

Explanation

Choice A rationale
Performing a thorough physical assessment is crucial when elder mistreatment is suspected. It helps to identify any signs of physical abuse or neglect.
Choice B rationale
Developing a safety plan is an important step in ensuring the safety of the elder. This plan can include strategies to avoid potential harm and steps to take if the elder feels unsafe.
Choice C rationale

Taking photographs to document the abuse or neglect can provide concrete evidence of the mistreatment. These photographs can be used in investigations and legal proceedings.
Choice F rationale
Completing a comprehensive history is necessary to understand the full context of the elder’s situation. This includes the elder’s health status, living conditions, and the nature of their relationship with the caregiver.
Choice H rationale
Reporting findings to Adult Protective Services is a critical step in addressing elder mistreatment. Adult Protective Services can conduct further investigations and take necessary actions to protect the elder.

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A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a first-time pregnant woman about preeclampsia. Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

What intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

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A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess.
In planning nursing care, which interventions should the nurse include? Select all that apply.