A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

Use non-steroidal anti-inflammatory drugs for discomfort.

Limit sodium in the diet to 3.5 g/day.

Place client in a lateral position.

Limit fluid intake to 2 liters/day.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Using non-steroidal anti-inflammatory drugs (NSAIDs) for discomfort is not recommended for patients with heart failure because NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also interfere with the effects of certain heart failure medications.

Choice B reason:

Limiting sodium in the diet to 3.5 g/day is not restrictive enough for heart failure patients. Typically, heart failure management involves reducing sodium intake to around 2-2.3 g/day to help prevent fluid retention and reduce the workload on the heart.

Choice C reason:

Placing the client in a lateral position is not specifically beneficial in the management of heart failure. While changing positions can be part of general patient care, it does not directly address the fluid balance or cardiac workload in heart failure patients.

Choice D reason:

Limiting fluid intake to 2 liters/day is a common intervention for managing heart failure. This helps to prevent fluid overload, which can exacerbate heart failure symptoms and lead to complications such as pulmonary edema. Maintaining a careful balance of fluid intake is essential for managing heart failure effectively.

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Correct Answer is D

Explanation

Choice A reason:

While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.

Choice B reason:

+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.

Choice C reason:

Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.

Choice D reason:

Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.

Correct Answer is ["83"]

Explanation

To calculate the infusion rate, divide the total volume of fluid to be infused by the total time over which the infusion should occur.

$\frac{330 \text{ mL}}{4 \text{ hours}} = 82.5 \text{ mL/hr}$

Rounding to the nearest whole number, the nurse should set the pump to deliver 83 mL/hr.

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A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Correct Answer is D

Explanation

A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr? Round to the nearest whole number.

Correct Answer is ["83"]

Explanation

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