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 C

Explanation

A) This choice is incorrect because an electrocardiogram (ECG) is a valuable diagnostic tool for assessing the heart's electrical activity and rhythm, but it is not the gold standard for diagnosing CHF. It can provide information about possible cardiac hypertrophy or rhythm disturbances associated with heart failure.

B) This choice is incorrect because a chest X-ray is helpful in evaluating heart size and the presence of pulmonary congestion, but it is not the gold standard for diagnosing CHF.

C) This choice is correct. An echocardiogram is the gold standard for diagnosing CHF. It uses ultrasound waves to assess the heart's structure and function, including ejection fraction and valve function, providing critical information to confirm the diagnosis of heart failure.

D) This choice is incorrect because a brain natriuretic peptide (BNP) level is a blood test that can aid in the diagnosis of CHF. Elevated BNP levels indicate heart strain, but it is not the gold standard for diagnosing CHF.

A. Avoid abrupt discontinuation of the medication. B. Take the medication with a high-fat meal. C. Limit fluid intake to prevent fluid overload. D. Take the medication in the evening to promote sleep.

Correct Answer is A

Explanation

A) This choice is correct. Beta-blockers should not be abruptly discontinued, as sudden discontinuation can lead to rebound effects and worsen the client's condition. Gradual tapering of the medication is necessary under the guidance of the healthcare provider.

B) This choice is incorrect because taking a beta-blocker with a high-fat meal is not necessary. Beta-blockers can be taken with or without food, but consistent administration is essential for optimal therapeutic effects.

C) This choice is incorrect because limiting fluid intake is not specific to the administration of beta-blockers. Fluid intake may need to be adjusted based on the client's overall fluid balance and congestive heart failure status, but it is not a direct instruction related to the medication.

D) This choice is incorrect because the timing of beta-blocker administration varies depending on the specific beta-blocker prescribed and the client's individual response. Some beta-blockers may be taken in the morning, while others may be taken in the evening. The client should follow the prescribed schedule given by the healthcare provider.

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

Correct Answer is C

Explanation

A nurse is caring for a client with congestive heart failure who is prescribed a beta-blocker. The nurse should instruct the client to:

Correct Answer is A

Explanation

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