A nurse is caring for a client with congestive heart failure who reports sudden weight gain, shortness of breath, and swelling in the ankles. What is the nurse's priority action?
Reassure the client that these symptoms are normal with CHF.
Encourage the client to increase fluid intake to prevent dehydration.
Notify the healthcare provider about the client's symptoms.
Administer a diuretic to reduce fluid retention.
The Correct Answer is C
A) This choice is incorrect because sudden weight gain, shortness of breath, and ankle swelling are not normal with CHF and may indicate worsening of the condition. The nurse should not reassure the client but rather take appropriate action to address the symptoms.
B) This choice is incorrect because the client's symptoms suggest fluid retention, and increasing fluid intake would exacerbate the condition. The nurse should not encourage the client to increase fluid intake without consulting the healthcare provider.
C) This choice is correct. The client's sudden weight gain, shortness of breath, and ankle swelling are signs of worsening congestive heart failure. The nurse's priority action is to notify the healthcare provider immediately to address the client's worsening condition and adjust the treatment plan as needed.
D) This choice is incorrect because administering a diuretic is not within the nurse's scope of practice without a healthcare provider's order. The nurse should first notify the healthcare provider to evaluate the client's condition and determine the appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
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 incorrect because hyperglycemia (high blood glucose levels) is not a common adverse effect of furosemide. In fact, furosemide can sometimes cause transient hypoglycemia.
C) This choice is correct. Hypotension (low blood pressure) is a potential adverse effect of furosemide due to its diuretic action. Furosemide causes the excretion of excess fluid, leading to a decrease in blood volume, which can result in hypotension.
D) This choice is incorrect because a dry, nonproductive cough is associated with ACE inhibitors, not furosemide.
Correct Answer is C
Explanation
A) This choice is incorrect because palpitations refer to an abnormal awareness of the heart's beating, which is not described by the client.
B) This choice is incorrect because angina pectoris is chest pain or discomfort due to inadequate blood flow to the heart muscle. The client's complaint is related to physical activity causing fatigue and weakness, not chest pain.
C) This choice is correct. Dyspnea on exertion refers to shortness of breath or difficulty breathing that occurs with physical activity or exertion. The client's symptoms of feeling fatigued and weak after mild activity suggest exertional dyspnea, which is common in congestive heart failure.
D) This choice is incorrect because peripheral cyanosis is bluish discoloration of the skin and mucous membranes due to reduced blood flow, which is not described by the client.
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