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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Free Nursing Study Resources

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.

A. Potassium B. BUN C. Allergy D. Respiratory rate E. Creatinine

Correct Answer is ["A","C","E"]

Explanation

A. Potassium: Spironolactone is a potassium-sparing diuretic. The client’s potassium level of 5.2 mEq/L is above normal, increasing the risk of hyperkalemia. Administering spironolactone in this context is contraindicated until potassium is corrected.

B. BUN: Although the BUN is elevated, indicating possible dehydration or renal impairment, it is not an absolute contraindication. Careful monitoring and dose adjustment may be necessary, but it does not automatically preclude spironolactone use.

C. Allergy: The client has a sulfonamide allergy. Spironolactone contains a sulfonamide group, which can trigger hypersensitivity reactions. This allergy is a clear contraindication to administering the medication.

D. Respiratory rate: The respiratory rate is within a reasonable range and does not affect the safety or efficacy of spironolactone. It is not a contraindication.

E. Creatinine: The elevated creatinine (1.7 mg/dL) indicates impaired renal function. Spironolactone can worsen hyperkalemia and fluid retention in clients with kidney dysfunction, making significant renal impairment a contraindication for its use.

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Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a client who has a new prescription for spironolactone. Which of the following client findings should the nurse identify as a contraindication to the administration of spironolactone? Select the 3 findings the nurse should identify as a contraindication.

Correct Answer is ["A","C","E"]

Explanation

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