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","B","D","E","F","G"]
Explanation
Rationale for correct findings:
- Client is urinating 100 mL/hour: This indicates improved kidney perfusion and rehydration. At 0900, the client reported frequent urination, which was likely osmotic diuresis leading to dehydration. A consistent urine output of 100 mL/hour suggests effective fluid resuscitation and that the kidneys are now functioning more optimally.
- Client is tolerating soft diet and oral fluids: The ability to tolerate a soft diet and oral fluids suggests that the client is recovering from nausea and dehydration. This is an important indicator of improvement in gastrointestinal function and overall metabolic status.
- Pulse rate decreased to 84/min: The pulse rate has decreased from 110/min to 84/min, indicating that the client’s cardiovascular status is improving, likely due to improved hydration and metabolic control.
- Blood pressure increased to 106/76 mm Hg: The client’s blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, reflecting a more stable circulatory volume and better perfusion. This improvement suggests that fluid resuscitation is helping to stabilize the client’s hemodynamic status.
- Blood glucose decreased to 310 mg/dL: A decrease in blood glucose from 468 mg/dL to 310 mg/dL shows that insulin therapy is having a positive effect on reducing hyperglycemia. The blood glucose level is still high but moving in the right direction, indicating recovery from the acute phase of hyperglycemia.
Rationale for Incorrect Finding:
- Bowel sounds are hyperactive in all 4 quadrants: Hyperactive bowel sounds remain unchanged from the initial assessment. It is not a sign of improvement, and could be related to the stress response, medications, or ongoing issues with the gastrointestinal system.
Correct Answer is ["3300"]
Explanation
Calculation:
- Calculate the total volume from the continuous IV infusion over 24 hours.
Continuous infusion rate = 125 mL/hr
Time = 24 hr
Volume from continuous infusion = 125 mL/hr × 24 hr
= 3000 mL.
- Calculate the total volume from the cefazolin IV bolus over 24 hours.
Cefazolin bolus volume per dose = 50 mL
Frequency = every 4 hr
Number of doses in 24 hr = 24 hr / 4 hr/dose
= 6 doses.
Volume from cefazolin bolus = 50 mL/dose × 6 doses
= 300 mL.
- Calculate the total IV fluid intake over 24 hours.
Total IV fluid intake = Volume from continuous infusion + Volume from cefazolin bolus
= 3000 mL + 300 mL
= 3300 mL.
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