A client with a history of hypertension and heart failure arrives for a scheduled clinic appointment and tells the nurse, "My feet are killing me. These shoes got so tight. The nurse's best initial action is to
Notify the health care provider
Take the client's pulse rate
Weigh the client.
Perform Osler's maneuver while checking blood pressure.
The Correct Answer is C
A. Notifying the healthcare provider may be necessary, but only after the nurse gathers more assessment data to support the report.
B. Taking the pulse rate is part of a routine assessment but does not directly address the client's complaint of tight shoes, which may indicate fluid retention.
C. Weighing the client is the best initial action because sudden weight gain and tight shoes can indicate fluid overload, a common issue in clients with heart failure. Daily weights help assess fluid status.
D. Osler's maneuver is not relevant in this context; it’s a rarely used technique and not appropriate for assessing peripheral edema or fluid status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypoglycemia is not a typical complication of hypokalemia or furosemide use.
B. Neurogenic shock results from spinal cord injury or dysfunction, not from low potassium levels.
C. Seizures are more commonly associated with hyponatremia or hypocalcemia, not mild hypokalemia.
D. Cardiac dysrhythmias are a primary concern with hypokalemia (such as a potassium level of 3.3 mEq/L), as low potassium can disrupt cardiac electrical activity and increase the risk of life-threatening arrhythmias.
Correct Answer is D
Explanation
A. Clients with heart failure typically require more frequent follow-up than twice a year, especially after a new diagnosis.
B. Activity restriction is not generally encouraged unless the client is symptomatic; regular physical activity (as tolerated) is beneficial in managing heart failure.
C. Nitroglycerin patches are not typically used for sudden chest pain; sublingual nitroglycerin is used for acute episodes.
D. A weight gain of 6 pounds (from 124 to 130 pounds) in one week may indicate fluid retention and worsening heart failure. Promptly notifying the healthcare provider is appropriate and demonstrates effective understanding of self-monitoring and management.
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