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. Brain Natriuretic Peptide (BNP) is a marker for heart failure, not the primary diagnostic test for myocardial infarction (MI).
B. Total Lactate Dehydrogenase (LDH) was historically used but is not specific for MI and has been replaced by troponin testing.
C. Troponin is correct. Cardiac-specific troponins (Troponin I and Troponin T) are the gold standard for detecting myocardial injury. Elevated levels indicate myocardial damage and are crucial for diagnosing MI.
D. Creatinine is important for assessing kidney function but is not a marker for myocardial infarction.

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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