A nurse is caring for a client who has heart failure.
Hold the client's metoprolol.
Increase the dosage of furosemide.
Decrease the client's oxygen to 1 L/min via nasal cannula.
Restrict the client's fluid intake to 2 L per day.
Weigh the client daily.
Begin a 24-hr urine collection for the client.
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Rationale:
- Hold the client's metoprolol: The client's heart rate is 112/min and irregular, and the ECG shows atrial fibrillation. Metoprolol helps manage heart rate. Holding it would worsen the tachycardia and the symptoms of heart failure. The blood pressure is also still elevated (146/82 mm Hg), indicating that the metoprolol is still needed.
- Increase the dosage of furosemide: The client’s weight has increased by 1.8 kg (4 lbs) within 24 hours, indicating fluid retention, which is a common symptom of heart failure. Increasing the dosage of furosemide will help manage fluid overload by promoting diuresis and reducing symptoms such as edema and shortness of breath.
- Decrease the client's oxygen to 1 L/min via nasal cannula: The client's oxygen saturation has decreased from 93% to 90% while on 2 L/min of oxygen. This indicates worsening oxygenation or increased oxygen demand due to fluid overload. The client needs continued or even increased oxygen.
- Restrict the client's fluid intake to 2 L per day: The client is showing signs of fluid overload (weight gain, decreased SpO2, elevated BNP). Fluid restriction is a necessary intervention in heart failure to manage fluid balance and prevent further accumulation of fluid
- Weigh the client daily: Daily weight monitoring is crucial in clients with heart failure to detect fluid retention early. A significant increase in weight can indicate worsening heart failure or fluid overload, which requires immediate intervention.
- Begin a 24-hr urine collection for the client: A 24-hour urine collection is used for assessing kidney function, electrolytes, and proteinuria. There is no immediate indication for this test in the current clinical scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Auscultate bowel sounds: While assessing bowel sounds can be important, it is not the priority action in this situation. The client is experiencing nausea, and the priority is to ensure their airway and safety, not just bowel function.
B. Turn the client on their side: Turning the client on their side is the priority action. This position helps prevent aspiration in case the client vomits, ensuring the airway remains clear and reducing the risk of aspiration pneumonia, especially after sedation.
C. Administer ondansetron: While ondansetron is effective for treating nausea, it is not the priority action in this case. The nurse should first ensure the client's safety by positioning them appropriately to prevent aspiration before administering medication.
D. Ensure suction equipment is available: Having suction equipment available is important for safety, but the immediate priority is positioning the client to prevent aspiration. Once the client is positioned safely, suction can be used if necessary, or be obtained if unavailable.
Correct Answer is C
Explanation
Rationale:
A. Three doses of nitroglycerin relieve the client's pain: While nitroglycerin can relieve chest pain related to angina, the fact that the pain subsides after three doses may indicate stable angina. However, this does not address the underlying concern if the pain began at rest, which is more concerning.
B. Pain radiates to the client's left arm: Pain radiating to the left arm is a common symptom of angina or myocardial infarction (MI). While this is concerning, it is not the most urgent finding compared to the pain onset, especially when pain occurs at rest.
C. Pain began in the morning while the client was resting: Chest pain occurring at rest, especially in the morning, is the most concerning symptom. This could indicate unstable angina or an impending myocardial infarction (MI). Unstable angina is more dangerous than stable angina and requires immediate intervention.
D. Pain is greatest in the client's substernal chest area: Substernal chest pain is characteristic of angina, but it is not as concerning as the timing of pain onset. Pain at rest, especially in the morning, suggests unstable angina or MI, which is a higher priority.
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