A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?
Administer diuretic medication as prescribed.
Elevate the client’s legs to reduce swelling.
Assess the client’s respiratory status and oxygen saturation.
Restrict fluid intake to prevent fluid overload.
The Correct Answer is C
Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Checking blood sugar levels before each meal is a good practice for managing diabetes and does not indicate a need for further teaching.
Choice B rationale
Skipping medication if blood sugar is normal indicates a misunderstanding of diabetes management. Medications should be taken as prescribed to maintain consistent blood sugar levels.
Choice C rationale
Following a balanced diet and exercising regularly are important components of diabetes management and do not indicate a need for further teaching.
Choice D rationale
Monitoring feet for cuts or sores is crucial for diabetes management to prevent complications like infections and ulcers.
Correct Answer is A
Explanation
Choice A rationale
Cerebral ischemia due to an embolus that originates in the left atrium is a common complication of chronic atrial fibrillation (AFib). AFib causes irregular and chaotic electrical signals in the atria, leading to poor blood flow and the formation of blood clots. These clots can travel to the brain, causing a stroke. This is the most acute and severe event associated with chronic AFib.
Choice B rationale
Development of ventricular fibrillation is a life-threatening arrhythmia that can occur in patients with severe heart disease, but it is not a common acute event in chronic AFib.
Ventricular fibrillation involves the ventricles and is characterized by rapid, erratic electrical impulses, leading to ineffective heart contractions and sudden cardiac arrest.
Choice C rationale
Ischemia of the cerebellum due to a ruptured intracranial aneurysm is not directly related to chronic AFib. While AFib increases the risk of stroke, it does not specifically cause aneurysms or cerebellar ischemia. Aneurysms are typically related to other risk factors such as hypertension and vascular abnormalities.
Choice D rationale
Prolonged capillary refill secondary to a complete lack of cardiac output is a sign of severe cardiac dysfunction or shock. While AFib can lead to heart failure and reduced cardiac output, it does not typically cause a complete lack of cardiac output. The most acute event related to AFib is the formation of emboli and subsequent stroke.
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