Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Encourage fluid intake

Administer prescribed diuretic as ordered.

Monitor daily weight and fluid intake/output.

Educate the patient about low-sodium dietary choices.

Answer and Explanation

Correct Answer : B,C,D

Choice A reason: Encouraging fluid intake worsens heart failure by increasing preload and congestion. Restriction (e.g., 2L/day) is standard to prevent overload, as excess volume exacerbates dyspnea and edema in compromised hearts.

Choice B reason: Administering diuretics like furosemide reduces fluid overload, easing heart failure symptoms. It lowers pulmonary pressure and edema by enhancing excretion, a critical action to stabilize patients and improve breathing.

Choice C reason: Monitoring weight and fluid balance tracks retention in heart failure; a 2-3 lb gain signals worsening. It guides therapy adjustments, ensuring effective management of volume status and preventing decompensation.

Choice D reason: Educating on low-sodium diets (<2g/day) prevents fluid retention in heart failure. Sodium draws water into vessels, worsening congestion; this empowers patients to control symptoms and supports long-term stability.

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Correct Answer is D

Explanation

Choice A reason: Tripod position aids breathing in COPD by stabilizing accessory muscles, a common adaptation. It signals distress but isn’t immediately life-threatening compared to respiratory rate, as it reflects chronic compensation rather than acute decompensation requiring urgent intervention.

Choice B reason: O2 saturation of 90% is low but typical in COPD due to ventilation-perfusion mismatch. It warrants monitoring, yet it’s less critical than respiratory rate, as supplemental oxygen can correct it, and it’s not an immediate danger sign.

Choice C reason: Bibasilar crackles suggest fluid or infection, uncommon in pure COPD exacerbations, which show wheezing. This finding needs attention but is less urgent than respiratory rate, as it may indicate pneumonia rather than immediate respiratory failure.

Choice D reason: Respiratory rate of 9 breaths/min is alarmingly low in COPD, where tachypnea (20-30 breaths/min) is expected during exacerbation. Bradypnea indicates potential respiratory depression or fatigue, risking CO2 retention and hypoxia, necessitating immediate reporting for intervention.

A. Staying indoors during cold and flu season B. Yearly flu vaccine C. Regular exercise and healthy nutrition D. Use a fan at night to circulate the air E. Staying away from crowds F. Handwashing G. Pneumonia Vaccine

Correct Answer is ["B","C","E","F","G"]

Explanation

Choice A reason: Staying indoors may limit exposure but isn’t practical or evidence-based for pneumonia prevention. It’s less effective than vaccines or hygiene, as pathogens persist indoors, reducing its priority in teaching.

Choice B reason: Yearly flu vaccine prevents influenza, a pneumonia risk factor, by inducing immunity. It’s a cornerstone of prevention, reducing respiratory infections that predispose to bacterial pneumonia, per public health guidelines.

Choice C reason: Regular exercise and nutrition boost immunity, reducing pneumonia risk. Strong lungs and host defenses limit infection severity, making this a key lifestyle topic for long-term respiratory health protection.

Choice D reason: Using a fan circulates air but doesn’t prevent pneumonia pathogens effectively. It may dry mucosa, increasing susceptibility, so it’s not a standard recommendation compared to vaccines or hygiene.

Choice E reason: Staying away from crowds reduces exposure to respiratory pathogens causing pneumonia. It’s practical during outbreaks, complementing vaccines and hygiene as a behavioral strategy to lower infection risk.

Choice F reason: Handwashing removes pathogens, preventing pneumonia transmission via contact. It’s a simple, evidence-based habit, critical in breaking infection chains, making it essential in patient education for prevention.

Choice G reason: Pneumonia vaccine (e.g., PCV13, PPSV23) protects against Streptococcus pneumoniae, a top cause. It’s a primary prevention tool, reducing incidence, strongly recommended for at-risk patients in teaching plans.

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Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Nursing Test Bank

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