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 B
Explanation
A) This choice is incorrect because a high-pitched, scratchy sound heard during inhalation is called a pleural friction rub and is associated with pleuritis or inflammation of the pleura, not congestive heart failure.
B) This choice is correct. An S3 heart sound is an extra heart sound heard immediately after S1 and S2, often described as a "ventricular gallop." It is associated with congestive heart failure and indicates increased fluid volume and strain on the ventricles.
C) This choice is incorrect because a prolonged, whooshing sound heard during systole is a heart murmur, which can be caused by various conditions, but it is not specific to the presence of an S3 sound.
D) This choice is incorrect because an irregular heart rhythm with varying intensity is characteristic of cardiac arrhythmias or irregular heartbeats and is not specific to the presence of an S3 sound.
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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