A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?
Encourage fluids.
Measure vital signs every 8 hr.
Obtain weight weekly.
Allow frequent rest periods.
The Correct Answer is D
The correct answer is choice D. Allow frequent rest periods.
Choice A rationale:
Encouraging fluids is not appropriate for a client with heart failure. Clients with heart failure often experience fluid overload due to the heart’s inability to pump effectively, leading to fluid retention. Encouraging additional fluid intake can exacerbate this condition, worsening symptoms such as edema and shortness of breath.
Choice B rationale:
Measuring vital signs every 8 hours may not be frequent enough for a client with heart failure, especially if they are experiencing acute symptoms. More frequent monitoring is often necessary to detect changes in the client’s condition promptly and to manage symptoms effectively.
Choice C rationale:
Obtaining weight weekly is not sufficient for a client with heart failure. Daily weight monitoring is crucial as it helps in detecting fluid retention early. Sudden weight gain can indicate worsening heart failure and the need for adjustments in treatment.
Choice D rationale:
Allowing frequent rest periods is essential for clients with heart failure. These clients often experience fatigue and decreased exercise tolerance due to reduced cardiac output. Frequent rest periods help in managing fatigue and preventing overexertion, which can worsen heart failure symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, herpes zoster. A 65-year-old client should receive the herpes zoster vaccine, which is recommended for adults over the age of 60 years to prevent shingles. Choice A is incorrect because inactivated polio virus vaccine is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus. Choice C is incorrect because the human papillomavirus vaccine is recommended for females aged 9-26 years and males aged 9-21 years. Choice D is incorrect because the measles, mumps, and rubella vaccine is recommended for individuals born after 1957 who have not had the vaccine or the diseases.
Choice A: Inactivated polio virus vaccine is incorrect because it is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus.
Choice C: Human papillomavirus vaccine is incorrect because it is recommended for females aged 9-26 years and males aged 9-21 years.
Choice D: Measles, mumps, and rubella vaccine is incorrect because it is recommended for individuals born after 1957 who have not had the vaccine or the diseases.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.
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