A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

Weight loss of 1 kg (2.2 lb) in the past 24 hr

Pale, clammy skin

Fatigue when ambulating 152 m (500 ft)

Productive cough with pink, frothy sputum

Answer and Explanation

The Correct Answer is D

A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.

It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.

Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.

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Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.

A. Apply rubber-soled slippers before ambulation. B. Move the bedside table with the client's personal items close to the bed. C. Determine the client's ability to use the call light. D. Create a schedule with an assistive personnel to do hourly rounding for the client.

Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

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A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

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