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?
Determine medication adherence by the client.
Teach the client about foods low in sodium.
Encourage the client to dangle the legs while sitting in a chair.
Notify the provider of the client's weight gain.
The Correct Answer is D
A. Determine medication adherence by the client:
This choice is incorrect as the nurse should first take immediate actions to address the client's weight gain and potential exacerbation of heart failure symptoms. While medication adherence is important, it's not the first action to take in this situation.
B. Teach the client about foods low in sodium:
This choice is incorrect as educating the client about sodium intake is important for managing heart failure, but the priority in this case is to address the current weight gain and potential worsening of the client's condition.
C. Encourage the client to dangle the legs while sitting in a chair:
This choice is incorrect. Dangling the legs while sitting in a chair can help improve blood circulation in some cases, but it's not the first action to take when the client has gained a significant amount of weight since the last visit. The priority should be addressing the weight gain and its potential impact on the client's heart failure.
D. Notify the provider of the client's weight gain:
This is the correct choice. When a client with heart failure experiences a sudden weight gain, it can indicate fluid retention and worsening of their condition. Notifying the healthcare provider about the weight gain is crucial to ensure timely assessment, potential medication adjustments, and other interventions to prevent further deterioration of the client's health. Prompt communication with the provider can help prevent complications associated with heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Morphine 6 mg IV push every 3 hr PRN acute pain:
This choice is correct. It accurately transcribes the medication name (morphine), the dosage (6 mg), the route (IV push), the frequency (every 3 hours), and the indication (PRN for acute pain).
B. Morphine 6.0 mg IV push every 3 hr PRN acute pain:
This choice is not incorrect, but it is unnecessary to include the trailing zero in the dosage (6.0 mg). Both "6" and "6.0" indicate the same value, and omitting the decimal point is common practice in medication dosages.
C. MS 6 mg IV push every 3 hr PRN acute pain:
This choice is incorrect. "MS" is an abbreviation for "morphine sulfate," but it's not widely used in modern healthcare settings. Using the full name "morphine" is clearer and less prone to confusion.
D. MSO4 6 mg IV push every 3 hr PRN acute pain:
This choice is incorrect. "MSO4" is the chemical symbol for morphine sulfate. While it's a valid abbreviation, it's not as commonly used as the full name "morphine." Using the full name of the medication is clearer and more familiar to healthcare professionals.
Correct Answer is D
Explanation
A. Another formulation of potassium should be given IV: The type of potassium formulation isn't the issue in this scenario.
B. Potassium chloride should be diluted in dextrose 5% in water: While potassium chloride can be administered in different solutions, the primary concern here is the infusion rate, not the specific diluent.
C. The client should be treated by giving potassium by IV bolus: The concern here is the rate of administration, not the route. Potassium is commonly administered through an IV infusion rather than a bolus due to the risk of cardiac arrhythmias associated with rapid administration.
D. A nurse is caring for a client who is to receive potassium replacement. The nurse should clarify the prescription with the provider because the potassium infusion rate is too rapid.
The prescription indicates that the client should receive potassium chloride 30 mEq in 0.9% sodium chloride 100 mL IV over 30 minutes. This rate of administration is too fast for potassium replacement and could lead to potentially serious complications, such as hyperkalemia or cardiac arrhythmias. The typical recommended rate for potassium replacement is 10-20 mEq/hour, and this prescription exceeds that range.
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