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, specify if the prescription is anticipated, nonessential, or contraindicated for the client)
Potential Prescriptions
Place the client on 24-hr urine collection.
Request to hold the client's metoprolol.
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.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"A"}}
Based on the information provided and the search results, here are the potential actions the nurse should take:
Choice A. nonessential
Reason: A 24-hour urine collection helps diagnose kidney problems. However, there is no clear indication from the provided information that the patient has kidney issues. Therefore, this prescription is at this point.
Choice B. nonessential
Reason: Metoprolol is a beta-blocker used in the treatment of heart failure. There is no clear indication from the provided information that the patient is experiencing adverse effects from metoprolol that would necessitate holding the medication.
Choice C. contraindicated
Reason: For people with heart failure, restricting dietary sodium intake to levels below the standard recommended maximum of about 2.3 grams per day does not bring additional benefits and may increase the risk of death.
Choice D. anticipated
Reason: Furosemide is a diuretic used in the treatment of heart failure. The patient's weight has increased, which could indicate fluid retention, a common symptom of worsening heart failure. Therefore, this prescription is .
Choice E. contraindicated
Reason: Oxygen therapy is used in heart failure patients to ensure adequate oxygen supply. However, the patient's oxygen saturation has decreased from 93% to 90%.
Choice F. anticipated
Reason: Daily weight monitoring is crucial in heart failure management as it can help detect fluid retention, a common symptom of worsening heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: It is important to fast before a bronchoscopy to reduce the risk of aspiration during the procedure.
Choice B reason: While positioning may vary, the specific position is not as critical to the teaching as the fasting requirement.
Choice C reason: Monitoring vital signs is standard post procedure care but is not specific to the preprocedural teaching.
Choice D reason: Eating immediately after the procedure may not be advised due to the risk of aspiration until the gag reflex returns.
Correct Answer is C
Explanation
Choice A reason: A nonpalpable area of redness is not typically indicative of a positive tuberculin skin test.
Choice B reason: Ecchymosis is not a typical reaction to a tuberculin skin test and does not necessarily indicate a need for further testing.
Choice C reason: A palpable area of induration greater than 10 mm in diameter is considered a positive result in certain populations and requires further assessment.
Choice D reason: Tenderness at the injection site is common and does not alone indicate a need for further testing.
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