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 Ib) 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.
Determine medication adherence by the client.
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
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
The provider should be informed of this change as soon as possible to prevent further complications.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.
While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.
While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.
While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Acetaminophen is contraindicated in patients with severe hepatic impairment or severe active liver disease1 and should be used with caution in patients with hepatic impairment or active liver disease. Alcohol use disorder can cause liver damage and increase the risk of acetaminophen toxicity.
Choice A is wrong because hepatitis B vaccine within the last week is not a contraindication for receiving acetaminophen.
There is no evidence that acetaminophen interferes with the immune response to the vaccine or causes adverse effects.
Choice B is wrong because chronic kidney disease is not a contraindication for receiving acetaminophen.
Acetaminophen is mainly metabolized by the liver and has minimal renal excretion.
However, patients with chronic kidney disease should consult their doctor before taking acetaminophen as they may have other conditions that affect its use.
Choice C is wrong because diabetes mellitus is not a contraindication for receiving acetaminophen.
Acetaminophen does not affect blood glucose levels or interact with oral antidiabetic drugs.
However, patients with diabetes mellitus should consult their doctor before taking acetaminophen as they may have other conditions that affect its use.
Correct Answer is B
Explanation
Hot flashes are a common side effect of tamoxifen, which is hormone therapy for breast cancer that blocks the action of estrogen.
Tamoxifen can cause menopause-like symptoms in women, such as irregular or missing periods, vaginal discharge or bleeding, and mood changes. Choice A is wrong because tinnitus (ringing in the ears) is not a known side effect of tamoxifen.
Choice C is wrong because urinary frequency (needing to urinate more often) is not a known side effect of tamoxifen.
Choice D is wrong because constipation (difficulty passing stools) is not a known side effect of tamoxifen.
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