A nurse is admitting a client who has acute heart fallure. Which of the following prescriptions from the provider should the nurse anticipate?
Ambulate the client every 4 hr while awake.
Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr.
Provide the client with a 4 g sodium diet.
Administer enalapril 2.5 mg PO twice daily.
The Correct Answer is D
A. Although activity is encouraged, clients with acute heart failure may require rest to minimize cardiac demand.
B. Clients with acute heart failure typically need fluid restrictions, not boluses, which could exacerbate heart failure symptoms.
C. A low-sodium diet is usually recommended for heart failure clients to help manage fluid retention, not a high-sodium diet.
D. Enalapril is an ACE inhibitor often prescribed for clients with heart failure as it helps reduce blood pressure and decrease the workload on the heart.
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Related Questions
Correct Answer is C
Explanation
A. While evaluating uterine tone is part of routine labor monitoring, it does not address the urgent need to relieve pressure on the prolapsed umbilical cord.
B. Keeping the cord moist is less of a priority than immediate measures to relieve pressure on the cord.
C. For a prolapsed umbilical cord, the immediate goal is to relieve pressure on the cord to maintain fetal oxygenation. Placing the client in the Trendelenburg position or a knee-to-chest position can help reduce the pressure on the cord by using gravity to shift the fetal presenting part toward the diaphragm.
D. Applying fundal pressure is contraindicated in the case of umbilical cord prolapse as it can increase pressure on the cord and exacerbate fetal distress.
Correct Answer is B
Explanation
A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.
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