A nurse is caring for a client with congestive heart failure. Which assessment finding may indicate a potential precipitating factor for the client's condition?
Body mass index (BMI) of 22 kg/m²
Blood pressure of 120/80 mmHg
Fasting blood glucose level of 90 mg/dL
Serum cholesterol level of 240 mg/dL
The Correct Answer is D
A) This choice is incorrect because a body mass index (BMI) of 22 kg/m² is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.
B) This choice is incorrect because a blood pressure of 120/80 mmHg is within the normal range and does not indicate a direct precipitating factor for congestive heart failure in this case.
C) This choice is incorrect because a fasting blood glucose level of 90 mg/dL is within the normal range and is not directly associated with the development of congestive heart failure in this scenario.
D) This choice is correct. A serum cholesterol level of 240 mg/dL indicates high cholesterol, which is a risk factor for coronary artery disease. Coronary artery disease is a leading cause of congestive heart failure and may have contributed to the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because limiting fluid intake to 1 liter per day is too restrictive and may lead to dehydration. Fluid restriction is essential for some clients with CHF, but the specific limit should be determined by the healthcare provider based on the client's individual needs.
B) This choice is incorrect because fluid restriction should not be limited to the evening only. Clients with CHF should monitor their fluid intake throughout the day to prevent fluid overload.
C) This choice is incorrect because drinking fluids primarily with meals may not be sufficient for managing fluid intake. Fluid intake should be balanced throughout the day to avoid excessive fluid retention.
D) This choice is correct. Monitoring daily weights is an essential strategy for clients with congestive heart failure to manage fluid balance. Sudden weight gain can indicate fluid retention, a common symptom of CHF. Clients should be instructed to report any significant weight changes to their healthcare provider promptly.
Correct Answer is B
Explanation
A) This choice is incorrect because bradycardia (slow heart rate) is not a common adverse effect of furosemide, a loop diuretic.
B) This choice is correct. Furosemide is a loop diuretic that can lead to increased potassium excretion in the urine, potentially causing hypokalemia (low potassium levels). The nurse should closely monitor the client's potassium levels and provide potassium supplementation if necessary.
C) This choice is incorrect because hypertension (high blood pressure) is not typically associated with loop diuretics like furosemide. In fact, furosemide is used to treat hypertension and congestive heart failure by promoting the excretion of excess fluid and reducing blood pressure.
D) This choice is incorrect because hyperglycemia (high blood glucose levels) is not a common adverse effect of furosemide. In fact, furosemide can sometimes cause transient hypoglycemia.
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