A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Administer diuretics.

Limit the client's fluid intake.

Insert an indwelling urinary catheter.

Place the client on a low-sodium diet.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.

B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.

C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.

D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.

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Correct Answer is A

Explanation

Rationale:

A. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.

B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.

C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.

D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.

A. Take mineral oil at bedtime. B. Decrease insoluble fiber intake. C. Increase exercise activity. D. Drink 1.5 L of fluids each day.

Correct Answer is C

Explanation

Rationale:

A. Take mineral oil at bedtime: Mineral oil is not recommended for long-term use because it can interfere with absorption of fat-soluble vitamins and may lead to aspiration pneumonia, especially in older adults. Safer stool softeners or laxatives should be used for opioid-induced constipation.

B. Decrease insoluble fiber intake: Insoluble fiber, such as wheat bran, helps bulk the stool and promote bowel movements. Reducing fiber intake can worsen constipation rather than relieve it, especially in clients taking opioids.

C. Increase exercise activity: Regular physical activity stimulates peristalsis and helps prevent constipation. Movement is a key non-pharmacologic strategy to counteract the slowed gastrointestinal motility caused by opioids.

D. Drink 1.5 L of fluids each day: Although hydration is important, adults typically require around 2 to 3 liters of fluid daily unless contraindicated. Limiting intake to 1.5 L may be insufficient to support normal bowel function and soften stool.

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A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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