A nurse is caring for a client with heart failure who has reported gaining 6 lbs over the past week. Which independent intervention should the nurse implement first?
Increase the client's fluid intake.
Arrange for a follow-up with the cardiologist
Administer diuretics as prescribed.
Educate the client on low sodium diet importance.
The Correct Answer is D
A. Increase the client's fluid intake: Increasing fluids would worsen fluid retention and exacerbate heart failure symptoms. This action is inappropriate for sudden weight gain related to fluid overload.
B. Arrange for a follow-up with the cardiologist: While follow-up is important, arranging an appointment is not an immediate independent nursing intervention. It addresses long-term management rather than the first nursing response.
C. Administer diuretics as prescribed: Administering medication is a dependent intervention that requires a provider’s order. Nurses cannot independently initiate or adjust diuretics without a prescription.
D. Educate the client on low sodium diet importance: Patient education is an independent nursing intervention. Teaching the client about sodium restriction helps prevent further fluid retention, addresses the cause of weight gain, and can be implemented immediately, making it the first priority action.
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Related Questions
Correct Answer is D
Explanation
A. Ineffective airway clearance: This diagnosis focuses on obstruction of the airway by secretions or mechanical blockage. While relevant to some respiratory conditions, it does not directly address gas exchange impairment or the client’s anxiety.
B. Risk for infection: This diagnosis addresses potential for infection rather than current acute symptoms. It is preventive in nature and does not target immediate respiratory compromise or emotional distress.
C. Anxiety related to hospitalization: This diagnosis addresses only the psychological component. While the patient is anxious, this alone does not encompass the physiological issue of impaired oxygenation.
D. Impaired gas exchange related to anxiety and respiratory distress: This diagnosis integrates both physiologic and psychological factors affecting oxygenation. Anxiety can exacerbate respiratory distress, and this NANDA diagnosis allows for interventions targeting both improved oxygenation and anxiety reduction.
Correct Answer is C
Explanation
A. Perform passive range-of-motion exercises daily: Passive ROM helps maintain joint mobility and circulation, but it does not directly relieve pressure on bony prominences. While beneficial, it is not the most immediate intervention to prevent pressure injuries.
B. Encourage fluid intake to maintain hydration: Adequate hydration supports skin turgor and overall tissue health, reducing susceptibility to breakdown. However, hydration alone cannot relieve sustained pressure, so it is not the highest-priority action.
C. Reposition the patient every 2 hours: Frequent repositioning redistributes pressure over bony areas, preventing ischemia and tissue necrosis. For patients with limited mobility, this is the primary and most effective intervention to reduce the risk of pressure injuries.
D. Apply moisturizing lotion to dry skin: Moisturizing helps prevent skin dryness and minor abrasions, supporting skin integrity. It does not alleviate pressure on vulnerable areas and is therefore a secondary preventive measure rather than the priority intervention.
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