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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because TB is caused by a bacterium that can develop resistance to single-drug therapy, so a combination of drugs is used to prevent or treat drug-resistant strains. Some of the common drugs used for TB are isoniazid, rifampin, ethambutol, and pyrazinamide.
Choice A is wrong because the duration of treatment for active TB is usually 6 to 9 months, not 3 years.
Choice B is wrong because tuberculin skin tests are not reliable indicators of disease activity or response to treatment, as they can remain positive for years after successful therapy.
Choice C is wrong because blood tests to monitor kidney function are not routinely required for TB treatment unless the client has a preexisting renal impairment or is taking drugs that are nephrotoxic.
Correct Answer is D
Explanation
The client will need to have blood levels drawn to monitor the therapeutic and toxic levels of theophylline, a bronchodilator that is used to treat symptoms of asthma and other lung conditions. The normal range of theophylline in the blood is 10 to 20 mcg/mL.
Choice A is wrong because the client should not sprinkle the medication in applesauce or any other food. Theophylline is a sustained-release capsule that should be swallowed whole and not crushed or chewed.
Choice B is wrong because the client should avoid caffeine while on this medication, as it can increase the side effects of theophylline, such as nausea, vomiting, headache, and irregular heart rate.
Choice C is wrong because the client should not limit fluid intake while on this medication unless instructed by the doctor.
Fluid intake helps prevent dehydration and kidney problems that can affect theophylline levels in the blood.
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