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 B

Explanation

Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.

Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).

A. Elevate the head of the bed. B. Send the emesis sample to the lab. C. Complete a focused assessment. D. Offer PRN pain medication.

Correct Answer is C,A,B,D

Explanation

Choice C rationale

The first step in managing a patient with abdominal pain and distention is to complete a focused assessment. This will help the nurse determine the severity of the patient’s condition and guide subsequent interventions.

Choice A rationale

Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited. This is particularly important in this case as the patient’s vomit is dark brown, indicating possible upper gastrointestinal bleeding.

Choice B rationale

Sending the emesis sample to the lab is important for determining the cause of the patient’s symptoms. The lab can analyze the sample for the presence of blood or other abnormalities.

Choice D rationale

Offering PRN pain medication is important for patient comfort. However, it should be done after the assessment and initial interventions have been completed. The medication may mask symptoms that could provide important diagnostic information.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is C,A,B,D

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.