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 A

Explanation

A. Alcohol relaxes throat muscles, worsening obstructive sleep apnea (OSA). The client should be educated to avoid alcohol, even while using a CPAP machine.
B. CPAP improves sleep quality and reduces daytime sleepiness, making this statement accurate.
C. Weight loss can reduce the severity of OSA, and some clients may no longer need treatment after significant weight loss.
D. The CPAP machine functions by delivering continuous air pressure to keep the airway open, which is a correct statement.

A. Encouraging the client to drink 2 to 3 L of water daily B. Maintaining a semi-Fowler's position as often as possible C. Administering oxygen via nasal cannula at 2 L/min D. Helping the client select a low-salt diet

Correct Answer is A

Explanation

A. Adequate hydration helps thin mucus secretions, making them easier to expectorate. Drinking 2 to 3 L of water daily is recommended unless contraindicated by another condition.
B. Semi-Fowler's position can help with breathing but does not directly aid in thinning secretions.
C. Oxygen therapy helps with oxygenation but does not address thick mucus.
D. A low-salt diet may be beneficial for overall health but does not directly impact mucus consistency.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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