A nurse is caring for a patient with heart failure. Which of the following nursing interventions is most appropriate to monitor fluid status in this patient?

Weigh the patient daily at the same time each day

Encourage fluid intake of at least 3 liters per day

Restrict sodium intake to less than 5 grams per day

Monitor oxygen saturation every 4 hours

Answer and Explanation

The Correct Answer is A

A. Daily weight measurement at the same time each day is the most accurate and effective method for monitoring fluid status in a patient with heart failure. A sudden increase in weight can indicate fluid retention.
B. Encouraging fluid intake of 3 liters per day is contraindicated in heart failure, where fluid restriction is often necessary to prevent volume overload.
C. Sodium restriction is important, but less than 2–3 grams per day is usually recommended for heart failure, not 5 grams. Also, while helpful, this does not directly monitor fluid status.
D. Monitoring oxygen saturation helps assess respiratory status but does not directly monitor fluid balance.

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Correct Answer is D

Explanation

A. Hold the medication in the mouth for 15 seconds before swallowing — This is incorrect. Inhaled glucocorticoids are meant to be inhaled into the lungs, not held in the mouth or swallowed.
B. Take the medication immediately when an attack starts — Inhaled glucocorticoids are not rescue medications. They are used for long-term control and prevention, not for acute asthma attacks.
C. Do not abruptly stop taking this medication: it must be tapered off — This applies to systemic (oral or IV) corticosteroids, not inhaled forms. Inhaled glucocorticoids have minimal systemic effects and do not require tapering.
D. Immediately rinse the mouth following the administration of the drug — This is correct. Rinsing the mouth helps prevent oral candidiasis (thrush), a common side effect of inhaled corticosteroids.

A. Stop the infusion B. Elevate the head of the bed C. Auscultate the client's breath sounds D. Call the client's provider

Correct Answer is A

Explanation

A. Stop the infusion — This is the priority action. The client is showing signs of a possible allergic reaction or anaphylaxis. Stopping the offending agent immediately prevents further exposure and progression of symptoms.
B. Elevate the head of the bed — This may help ease breathing but is not the first priority. The first step is to stop the infusion to halt the allergic reaction.
C. Auscultate the client's breath sounds — While assessing respiratory status is important, the immediate priority is to stop the medication causing the reaction.
D. Call the client's provider — Notifying the provider is necessary, but it is not the first step. Immediate intervention is required to stop the reaction before it worsens.

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A nurse is caring for a patient with heart failure. Which of the following nursing interventions is most appropriate to monitor fluid status in this patient?

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Naxlex Comprehensive Predictor Exams

The client, who has been diagnosed with asthma, has been prescribed an inhaled glucocorticoid medication. Which information should the nurse teach about this medication?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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