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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pleural effusion is a common complication of heart failure. Increased pressure in the pulmonary circulation can cause fluid to accumulate in the pleural space, leading to dyspnea and decreased lung expansion.
B. Infection is not a direct complication of heart failure. However, individuals with heart failure may have an increased risk of infections due to a weakened immune system.
C. Asthma is not a complication of heart failure. While both conditions can cause shortness of breath, asthma is a separate respiratory disorder.
D. Hemorrhage is not associated with heart failure. Instead, heart failure can lead to clotting abnormalities or increased bleeding risk if the client is on anticoagulants.
Correct Answer is D
Explanation
A. Taking 4 nitroglycerin tablets is incorrect. The maximum dose is 3 tablets, taken 5 minutes apart. If chest pain persists after the third dose, the client should seek emergency help.
B. Calling 911 after only one dose is incorrect. The correct protocol is to take up to three doses before seeking emergency assistance unless symptoms worsen rapidly.
C. Calling 911 immediately before taking nitroglycerin is incorrect. The client should attempt to relieve the chest pain with nitroglycerin before calling for emergency help.
D. Calling 911 if pain persists after taking 3 nitroglycerin tablets 5 minutes apart is correct. Persistent chest pain despite nitroglycerin use suggests a possible myocardial infarction (MI), requiring immediate medical intervention.
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