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 D
Explanation
A) This choice is incorrect because while electrolyte imbalances can have cardiovascular implications, they are not directly associated with diabetes mellitus or congestive heart failure.
B) This choice is incorrect because left-sided heart failure is not directly related to uncontrolled diabetes mellitus. However, diabetes can exacerbate heart failure if not well-controlled due to its impact on blood vessels and the heart.
C) This choice is incorrect because decreased afterload is not directly related to uncontrolled diabetes mellitus. Afterload refers to the resistance the heart has to overcome to eject blood into the circulation.
D) This choice is correct. Uncontrolled diabetes mellitus can lead to microvascular damage, particularly in the small blood vessels of the heart. This damage can contribute to heart muscle dysfunction and congestive heart failure. Diabetes is a significant risk factor for developing heart failure.
Questions
Correct Answer is B
Explanation
A) This choice is incorrect because taking the nitrate medication with food is not necessary. Nitrate medications are usually taken sublingually or by mouth and are not associated with significant stomach upset.
B) This choice is correct. Nitrate medications, such as nitroglycerin, can cause a dangerous drop in blood pressure when used concurrently with erectile dysfunction medications, specifically phosphodiesterase type 5 inhibitors (PDE5 inhibitors) like sildenafil (Viagra) or tadalafil (Cialis). Clients should be warned against using these medications together to prevent hypotension and potential cardiovascular complications.
C) This choice is incorrect because grapefruit juice is not typically associated with nitrate medications. Grapefruit juice can interact with certain medications, but it is not a known interaction with nitrates.
D) This choice is incorrect because increasing the nitrate dose without healthcare provider guidance can be dangerous. Clients should be instructed to take nitrate medications as prescribed and seek immediate medical attention if chest pain is not relieved within a specific timeframe, as directed by their healthcare provider.
Questions
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