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 A
Explanation
Rationale:
A. Provide analgesic medication prior to physical activities: Administering analgesic medication prior to physical activities helps facilitate recovery by minimizing pain, which can encourage the client to engage in necessary activities such as deep breathing, coughing, and ambulation to prevent complications like pneumonia or blood clots.
B. Administer naloxone if the client's respiratory rate is greater than 24/min: Naloxone is used to reverse opioid overdose, particularly if the respiratory rate is low (less than 12/min). A respiratory rate greater than 24/min does not require naloxone administration.
C. Withhold analgesic medication unless the client reports pain: Withholding analgesics can hinder the client's ability to participate in activities necessary for recovery. Managing pain proactively, rather than reactively, is essential to help the client with early mobilization.
D. Inform the client to monitor for loose stools while taking opioid analgesia: Opioids are more likely to cause constipation rather than loose stools. Clients taking opioid analgesia should be informed about the risk of constipation..
Correct Answer is D
Explanation
Rationale:
A. "Keep your elbow in a flexed position." Keeping the elbow in a flexed position increases the risk of contractures, particularly in the case of upper body burns. The goal is to keep the joints extended to prevent the development of contractures.
B. "Remain in a side-lying position." A side-lying position is not ideal for preventing contractures in the upper body. The client should be positioned to minimize pressure on the burn areas and encourage joint mobility, often with the client in a supine or elevated position.
C. "Place a firm pillow under your head." Placing a firm pillow under the head might cause the neck to flex, which could lead to neck contractures. A proper head and neck alignment should be maintained to avoid such complications.
D. "Wear splints on your wrists." Wearing splints on the wrists helps to keep the joints in proper alignment and prevents contractures by maintaining wrist extension. This is an appropriate intervention for clients with upper body burns to promote healing and function.
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