A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure.
Which of the following is the priority topic for the nurse to review with the client?
Daily exercise routine.
Daily sodium restrictions.
Fluid intake record.
Changes in weight.
The Correct Answer is D
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should instruct the client to wash their perineal area two times each day with antimicrobial soap.
This is important because chemotherapy can weaken the immune system, making the client more susceptible to infections.
Choice B is wrong because washing a toothbrush in a dishwasher once a month is not an effective way to prevent infection.
Choice C is wrong because changing a pet’s litter box daily could expose the client to harmful bacteria and should be avoided.
Choice D is wrong because changing the water in a drinking glass every 4 hours is not necessary for preventing infection.
Correct Answer is C
Explanation
The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.
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