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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) This choice is incorrect because hypernatremia (high sodium levels) is not a common adverse effect of loop diuretics. Loop diuretics primarily impact sodium and water excretion.

B) This choice is incorrect because hyperkalemia (high potassium levels) is not typically associated with loop diuretics. In fact, loop diuretics can lead to increased potassium excretion, potentially causing hypokalemia.

C) This choice is incorrect because hypocalcemia (low calcium levels) is not a common adverse effect of loop diuretics. Loop diuretics primarily affect sodium, potassium, and water excretion.

D) This choice is correct. Loop diuretics are potent potassium-wasting diuretics, meaning they increase potassium excretion in the urine, potentially causing hypokalemia. The nurse should closely monitor the client's potassium levels and provide potassium supplementation if necessary.

A. Narrowed mediastinum B. Hyperinflated lungs C. Cardiomegaly D. Normal cardiac silhouette

Correct Answer is C

Explanation

A) This choice is incorrect because a narrowed mediastinum is not a characteristic finding in congestive heart failure. The mediastinum is the central region of the chest, and its width is not specifically related to CHF.

B) This choice is incorrect because hyperinflated lungs are a characteristic finding in chronic obstructive pulmonary disease (COPD), not congestive heart failure.

C) This choice is correct. Cardiomegaly, an enlarged heart, is a common finding in congestive heart failure. The heart may appear enlarged on a chest X-ray due to fluid accumulation and strain on the heart muscle.

D) This choice is incorrect because a normal cardiac silhouette on a chest X-ray would not be indicative of congestive heart failure. The presence of cardiomegaly is more suggestive of heart failure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with congestive heart failure who is prescribed a loop diuretic. The nurse should monitor the client for which potential electrolyte imbalance associated with this medication?

Correct Answer is D

Explanation

A client with suspected congestive heart failure undergoes a chest X-ray. The nurse should anticipate which finding that may be indicative of CHF?

Correct Answer is C

Explanation

A client with a history of alcohol abuse and malnutrition is admitted with signs and symptoms of congestive heart failure. Which factor is likely a precipitating cause of the client's condition?

A client with suspected congestive heart failure undergoes an echocardiogram. The nurse should expect which parameter to be measured during the echocardiogram to assess the client's heart function?

A nurse is providing education to a client with congestive heart failure who is prescribed an angiotensin-converting enzyme (ACE) inhibitor. The nurse should instruct the client to:

A client with congestive heart failure is prescribed digoxin. The nurse should monitor the client's:

A client with congestive heart failure is prescribed furosemide, a loop diuretic. The nurse should monitor the client for which potential adverse effect of this medication?

A nurse is reviewing the diagnostic tests for a client suspected of having congestive heart failure. Which test is considered the gold standard for diagnosing CHF?

A client with congestive heart failure is prescribed a daily dose of furosemide. The nurse should monitor the client for which potential adverse effect of this medication?

A nurse is auscultating a client's heart sounds and hears a third heart sound (S3). Which finding is consistent with the presence of an S3 sound in a client with congestive heart failure?