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.

Answer and Explanation

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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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.

A. Position the client in reverse Trendelenburg. B. Assist the client into the lithotomy position. C. Insert a pillow under the client's knees. D. Place a wedge under one of the client's hips.

Correct Answer is D

Explanation

A. Positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration.
B. The lithotomy position is not appropriate for cesarean birth and may compromise blood flow to the placenta.
C. This position could increase pressure on the vena cava and compromise placental blood flow.
D. This lateral tilt relieves pressure on the inferior vena cava, preventing decreased placental blood flow.

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A nurse is admitting a client who has acute heart fallure. Which of the following prescriptions from the provider should the nurse anticipate?

Nursing Test Bank

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