A nurse is assessing a client who has heart failure.
Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?
"I will weigh myself daily.".
"l hate how I feel all the time.".
"I'm too tired to brush my teeth.".
"I need to start eating a low-sodium diet.".
The Correct Answer is C
“I’m too tired to brush my teeth.” This statement indicates that the client is experiencing fatigue, which is a common symptom of heart failure.
Fatigue can significantly impact a person’s ability to perform daily activities and can be an indication that the client needs a referral for cardiac rehabilitation 1.
Choice A is not the correct answer because weighing oneself daily is a recommended self-monitoring technique for clients with heart failure.
Choice B is not the correct answer because while feeling unhappy can be a symptom of heart failure, it does not necessarily indicate a need for cardiac rehabilitation.
Choice D is not the correct answer because eating a low-sodium diet is a recommended dietary change for clients with heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Initiate a referral for the client to a home health agency.
This action demonstrates client advocacy because it empowers the client to continue self-care at home while also providing them with additional support and resources through the home health agency.
Choice A is wrong because avoiding large crowds of people is a precautionary measure but does not demonstrate client advocacy.
Choice B is wrong because avoiding raw vegetables is a dietary recommendation but does not demonstrate client advocacy.
Choice C is wrong because reminding the client of the importance of medication adherence is important but does not demonstrate client advocacy.
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
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