A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Provide a bedside commode for toileting.

Assist with ambulation in the hallway.

Teach to sleep in a side-lying position.

Encourage active range of motion exercises.

Answer and Explanation

The Correct Answer is A

A. Provide a bedside commode for toileting: This intervention helps reduce the cardiac workload by minimizing the effort needed for the client to walk to the bathroom. It allows the client to conserve energy and reduce the strain on the heart.

B. Assist with ambulation in the hallway: While mobility is important, ambulating in the hallway can increase the heart’s workload, especially in a client with heart failure and pneumonia. It's best to minimize unnecessary physical exertion to prevent exacerbations.

C. Teach to sleep in a side-lying position: While side-lying can sometimes help with breathing, this position does not directly reduce the cardiac workload. The priority is ensuring the client has adequate rest and minimizing physical strain.

D. Encourage active range of motion exercises: While range of motion exercises are important for preventing complications like muscle atrophy, they may increase the cardiac workload. For a client with pneumonia and heart failure, the priority is to reduce exertion and conserve energy.

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Correct Answer is C

Explanation

A. Loperamide: Although it treats diarrhea, loperamide would worsen ammonia buildup by reducing bowel transit time. It doesn’t address the underlying hepatic encephalopathy causing confusion in cirrhosis.

B. Furosemide: This loop diuretic is used to manage ascites or edema, not elevated ammonia. It doesn’t treat the neurological symptoms caused by hepatic encephalopathy or improve stool-based ammonia excretion.

C. Lactulose: Lactulose lowers serum ammonia by trapping it in the colon and promoting its excretion through diarrhea. It directly treats confusion related to hepatic encephalopathy, making it the most important intervention here.

D. Intravenous (IV) human albumin: Albumin helps restore oncotic pressure in cases of ascites or low serum protein but does not affect ammonia levels or mental status. It supports fluid balance, not toxin elimination.

A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. B. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. C. Document why the blood pressure cannot be accurately measured at the present time. D. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses.

Correct Answer is B

Explanation

A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet: Documenting a previous reading does not reflect the client’s current condition and can be misleading in decision-making. Vital signs should be based on real-time assessment.

B. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed: The popliteal site is appropriate for measuring blood pressure when the arms are inaccessible. Flexing the knee while the client is supine allows better access to the artery and enables accurate assessment of blood pressure in this situation.

C. Document why the blood pressure cannot be accurately measured at the present time: While documentation is necessary if no alternative is available, the nurse must first exhaust appropriate options for obtaining a blood pressure before choosing to omit it.

D. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses: Pulse volume gives a very rough estimate of perfusion but does not provide an accurate or objective blood pressure measurement. This method lacks precision.

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A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is B

Explanation

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