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 A

Explanation

Choice A reason: Low-impact exercise, like walking, enhances collateral circulation in PAD, increasing blood flow to ischemic muscles. It reduces claudication by stimulating angiogenesis and improving endothelial function, a cornerstone of evidence-based management to alleviate symptoms effectively.

Choice B reason: Limiting fluid intake addresses edema, not a primary PAD issue, which involves arterial insufficiency, not venous stasis. This strategy lacks scientific support for claudication relief, as hydration status doesn’t directly influence arterial perfusion.

Choice C reason: Tight shoes restrict circulation, worsening PAD by compressing arteries and exacerbating ischemia. Proper footwear is essential, but constriction contradicts vascular physiology, potentially increasing pain and tissue damage rather than improving blood flow.

Choice D reason: Bed rest reduces activity, promoting stasis and deconditioning in PAD, worsening claudication. Immobility decreases muscle pump action and collateral flow, conflicting with evidence that exercise improves symptoms, making this detrimental to recovery.

A. Give the PRN acetaminophen (Tylenol). B. Notify the health care provider of these findings. C. Obtain oxygen saturation using pulse oximetry. D. Give the scheduled IV antibiotic.

Correct Answer is B

Explanation

Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.

Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.

Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.

Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.

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

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Naxlex Comprehensive Predictor Exams

A 65-year-old patient with a history of Peripheral Artery Disease (PAD) presents to the clinic with complaints of intermittent claudication in the right leg. Which of the following management strategies should the nurse prioritize to improve the patient’s condition?

Correct Answer is A

Explanation

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Correct Answer is B

Explanation

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