A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in bilateral lower extremities. Which action should the nurse take next?

Encourage an increased intake of the client's favorite drink

Continue to monitor daily weights and edema and document findings.

Perform a head-to-toe assessment, including vital signs

Check the record to determine code status

Answer and Explanation

The Correct Answer is C

A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.

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Correct Answer is C

Explanation

A. A pulmonary function test is used to assess lung diseases like COPD or asthma. It is not the primary diagnostic test for fluid overload and heart failure.
B. Alpha-1 antitrypsin deficiency is associated with early-onset COPD, but it does not relate to symptoms of fluid retention and heart failure as described in the question.
C. Brain Natriuretic Peptide (BNP) is correct. BNP is released when the ventricles stretch due to fluid overload, making it a key diagnostic marker for heart failure. Elevated BNP levels indicate increased cardiac filling pressures and volume overload, which match the client’s symptoms.
D. A Doppler ultrasound is useful for detecting deep vein thrombosis (DVT) or vascular issues, but it does not assess systemic fluid retention and heart failure.

A. Headache B. Hypotension C. Constipation D. Nausea

Correct Answer is A

Explanation

A. Headache is correct. Clients with obstructive sleep apnea often experience morning headaches due to intermittent hypoxia and hypercapnia caused by repeated episodes of airway obstruction during sleep.
B. Hypotension is incorrect. Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension due to the body's stress response to low oxygen levels.
C. Constipation is not a common symptom of obstructive sleep apnea. Gastrointestinal symptoms are not typically associated with this condition.
D. Nausea is not a characteristic finding in obstructive sleep apnea. The primary symptoms involve respiratory and neurological effects due to oxygen deprivation during sleep.

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A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in bilateral lower extremities. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

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