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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.
B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.
C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.
D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.
Correct Answer is C
Explanation
A: Percussion should be performed with a cupped hand to provide effective airway clearance, not with a flat hand.
B: Postural drainage is typically performed multiple times per day to help clear secretions from the lungs in cystic fibrosis.
C: Postural drainage is often performed before meals to minimize the risk of vomiting due to manipulation of the abdomen.
D: Bronchodilators are not typically administered after postural drainage; they are used to help open the airways before the procedure.
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