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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb) since the last visit 2 days ago. Which of the following actions should the nurse take first?

Teach the client about foods low in sodium.

Encourage the client to dangle the legs while sitting in a chair.

Determine medication adherence by the client.

Notify the provider of the client's weight gain.

Answer and Explanation

The Correct Answer is D

A. Teaching about sodium is important but not an immediate action in response to weight gain.

B. Dangling the legs can help reduce edema but does not address the underlying cause of fluid retention.

C. Determining medication adherence is helpful but is secondary to addressing the acute concern of fluid retention.

D. Notifying the provider is the priority action. A 5 lb weight gain in 2 days may indicate fluid retention and worsening heart failure, requiring immediate intervention from the provider.

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Correct Answer is D

Explanation

A. A long-acting NSAID is not appropriate for breakthrough pain when a fentanyl patch is already in use, as it is not fast-acting enough.

B. Applying heat to the patch can increase the absorption of fentanyl, which could cause an overdose.

C. The fentanyl patch is a long-acting opioid, and a new patch should not be applied for breakthrough pain so soon.

D. A short-acting opioid is appropriate for treating breakthrough pain, as it provides rapid relief.

A. Maintain the extremity below the level of the heart. B. Slow the IV solution rate. C. Apply a warm, moist compress. D. Initiate a new IV distal to the initial site.

Correct Answer is C

Explanation

A. Maintaining the extremity below the level of the heart may worsen the edema and is not recommended for infiltration.

B. Slowing the IV solution rate may help reduce further fluid buildup but does not address the cool, edematous site.

C. Applying a warm, moist compress helps to reduce edema and promotes absorption of infiltrated fluid.

D. Initiating a new IV distal to the initial site is not the first action to take and should only be done if the site is not salvageable.

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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb) since the last visit 2 days ago. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for a fentanyl transdermal patch and had one patch applied 4 hr ago. The client reports breakthrough pain. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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