A nurse is caring for a client who has heart failure.

A nurse is caring for a client. After reviewing the findings above, which of the following actions should the nurse take? For each potential provider's prescription, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Place the client on 24- hr urine collection.

Place on sodium restriction of less than 1,500 mg per day.

Request for an increased dosage of furosemide.

Decrease the client's oxygen to 1 L/min via nasal cannula.

Weigh the client daily.

Request to hold the client's metoprolol.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"B"}}

Place the client on 24-hr urine collection: This is appropriate to monitor kidney function, fluid balance, and response to diuretics in a client with heart failure, especially with rapid weight gain.
Place on sodium restriction of less than 1,500 mg per day: Sodium restriction is standard in heart failure management to prevent fluid retention and reduce the risk of worsening edema and hypertension.
Request for an increased dosage of furosemide: The client shows weight gain (1.8 kg in 24 hr) and low oxygen saturation, suggesting fluid overload. Increasing the diuretic is an expected intervention to remove excess fluid.
Decrease the client's oxygen to 1 L/min via nasal cannula: The client’s oxygen saturation is 90% on 2 L/min, indicating hypoxemia. Reducing oxygen would worsen tissue oxygenation and is contraindicated.
Weigh the client daily: Daily weight monitoring helps detect early fluid retention or loss, which is critical in managing heart failure exacerbations.

Request to hold the client's metoprolol: Holding a beta-blocker without a clear contraindication (e.g., severe bradycardia, hypotension, or acute decompensation) is unnecessary. Continuing metoprolol helps control heart rate and manage atrial fibrillation.

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Correct Answer is ["B","D","E"]

Explanation

A. Blood pressure: The blood pressure reading of 140/90 mm Hg does not interfere with simvastatin therapy and does not increase the risk of adverse reactions. Statins do not significantly affect blood pressure, and hypertension alone is not a contraindication. This finding does not prevent safe administration of the medication.

B. Creatinine kinase: The creatine kinase level of 200 units/L is above the normal range and indicates possible muscle injury. Elevated CK increases concern for statin-associated myopathy, which can progress to rhabdomyolysis if the medication is continued. Withholding simvastatin until further evaluation protects the client from worsening muscle damage.

C. BUN: The BUN level of 15 mg/dL is normal and does not indicate renal impairment or dehydration. Simvastatin is not contraindicated in clients with normal kidney function. Because this value shows stable renal status, it does not affect the safety of initiating statin therapy.

D. Prescription for diltiazem: Diltiazem inhibits CYP3A4, the enzyme responsible for metabolizing simvastatin, and can significantly raise simvastatin levels. Higher serum concentrations increase the risk of severe myopathy and rhabdomyolysis. This drug interaction requires reconsideration of simvastatin dosing or alternative therapy.

E. Client report of muscle aches: Muscle pain is an early sign of statin-related myopathy and warrants immediate attention before giving another dose. Continuing the medication may worsen muscle breakdown and contribute to elevated CK levels. Holding the statin until the cause of the symptoms is evaluated promotes client safety.

A. Encourage the client to use a straw to sip cool liquids. B. Place the client in a semi-Fowler's position. C. Encourage the client to cough. D. Obtain the client's peak expiratory flow volume.

Correct Answer is B

Explanation

A. Encourage the client to use a straw to sip cool liquids: Using a straw can increase the risk of trauma to the surgical site, potentially causing bleeding. After a tonsillectomy, clients should sip liquids directly from a cup to protect the tonsillar area.

B. Place the client in a semi-Fowler's position: Semi-Fowler’s position promotes optimal lung expansion, improves oxygenation, and helps prevent airway obstruction. This position supports respiratory function and is appropriate for a client with an SpO2 of 93%.

C. Encourage the client to cough: Coughing can strain the surgical site and increase the risk of postoperative bleeding. Gentle deep breathing is preferred, while forceful coughing should be avoided until healing progresses.

D. Obtain the client's peak expiratory flow volume: Peak expiratory flow measurement is not routinely indicated after a tonsillectomy. Focus should be on monitoring oxygenation, airway patency, and signs of respiratory distress rather than lung function testing.

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Naxlex Comprehensive Predictor Exams

Which of the following client findings should the nurse identify as a contraindication to the administration of simvastatin? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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