A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Reinforce the importance of daily weights.

Call the health care provider for further instructions.

Document the findings and continue with the visit.

Ensure the client has been taking their prescribed diuretic.

Answer and Explanation

The Correct Answer is D

A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.

B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.

C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.

D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.

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Correct Answer is ["B","D","E","G"]

Explanation

A. Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis.
B. Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients.
C. Obtaining a wound culture is not a priority action in the initial management of sepsis.
D. Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients.
E. Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy.
F. Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis.
G. Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability.
H. Obtaining a urine specimen is not a priority action in the initial management of sepsis.

A. Brain trauma and injury B. Bone loss and osteoporosis C. Liver and pancreatic disease D. Heart disease and stroke

Correct Answer is D

Explanation

A. While methamphetamine use can lead to risky behaviors that may increase the risk of injury, it is not directly associated with brain trauma and injury.
B. Methamphetamine use is not directly associated with bone loss and osteoporosis.
C. Methamphetamine use is not directly associated with liver and pancreatic disease.
D. Methamphetamine use can lead to blood vessel constriction and spasming, which can increase the risk of heart disease and stroke.

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A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Correct Answer is ["B","D","E","G"]

Explanation

A nurse is caring for a client who regularly uses methamphetamine and is experiencing blood vessel constriction and spasming. The nurse should identify that the client is at high risk for developing which of the following conditions?

Correct Answer is D

Explanation

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