A patient with left-sided heart failure is being treated with enalapril and furosemide. Which assessments should the nurse perform to evaluate the effectiveness of these medications?

Monitor heart rate and rhythm.

Auscultate lung fields and check blood pressure (BP).

Assess for jugular venous distension (JVD).

Check peripheral pulses.

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring heart rate and rhythm is important in heart failure management, but it does not directly reflect the effectiveness of enalapril and furosemide, which are primarily used to control blood pressure and reduce fluid overload, respectively.

Choice B reason: Auscultating lung fields can reveal the presence of fluid, indicating pulmonary edema, a common complication of left-sided heart failure. Checking BP is essential as enalapril is an ACE inhibitor that lowers BP, and furosemide can also affect BP through its diuretic effect.

Choice C reason: Assessing for JVD can indicate right-sided heart failure, which may develop secondary to left-sided heart failure. However, it is not the primary assessment for the effectiveness of enalapril and furosemide.

Choice D reason: Checking peripheral pulses is a general assessment and, while important, it does not specifically evaluate the effectiveness of the medications in question.

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Correct Answer is C

Explanation

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

A. "I can sit down to put on my pants and shoes." B. "I try to exercise every day and rest when I am tired." C. "I do not need to use my walker to go to the bathroom." D. "My son removed all the loose rugs from the house."

Correct Answer is C

Explanation

Choice A reason: The statement about being able to sit down to put on pants and shoes indicates that the client is implementing safety measures to prevent falls, which is a positive outcome of effective teaching.

Choice B reason: Exercising daily and resting when tired is an appropriate strategy for managing Parkinson's disease symptoms, suggesting that the client has understood the education provided.

Choice C reason: The statement about not needing a walker could indicate a lack of understanding of the importance of mobility aids in preventing falls, which is a concern for clients with Parkinson's disease.

Choice D reason: Removing loose rugs from the house is a preventive measure to reduce fall risk, indicating that the client and family have understood and applied the education.

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A patient with left-sided heart failure is being treated with enalapril and furosemide. Which assessments should the nurse perform to evaluate the effectiveness of these medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Correct Answer is C

Explanation

The nurse is providing education to the client with Parkinson's disease and their family. The nurse understands that teaching has not been effective when the client makes which of the following statements?

Correct Answer is C

Explanation

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