A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Tachycardia

Weight gain

Decreased thirst

Thready pulse

Answer and Explanation

The Correct Answer is B

A.   While tachycardia can occur in some cases of heart failure as a compensatory mechanism, it's not a universal manifestation.
B.   In heart failure, weight gain is a common manifestation due to fluid retention caused by the heart's inability to pump blood effectively. This fluid buildup can lead to an increase in body weight, often evidenced by swelling in the legs, ankles, or abdomen.
C.   Heart failure often leads to increased thirst due to fluid overload and decreased cardiac output, resulting in poor tissue perfusion.
D.   A thready pulse may be present in heart failure due to decreased stroke volume, but it's not a primary manifestation typically associated with the condition.

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Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

A. Give the dose over 60 min. B. Administer the medication undiluted. C. Inject 19% lidocaine prior to each dose. D. Obtain a trough level 30 min after the medication infusion.

Correct Answer is A

Explanation

A. Administering vancomycin over a longer infusion time, such as 60 minutes, can help reduce the risk of adverse reactions, such as red man syndrome or nephrotoxicity. Slower infusion rates allow for better tolerance of the medication.
B. Vancomycin should be diluted appropriately before administration to reduce the risk of infusion-related reactions.
C. Lidocaine is not typically used prior to vancomycin administration. The use of lidocaine would be more relevant for local anesthesia, not for systemic medication administration like vancomycin.

D. Trough levels are typically obtained just before the next dose of vancomycin is due, not immediately after the infusion.

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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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