The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

Teach family members to assist with all ADLS once discharged

Cluster activities to a time when the client has the most energy

Provide alternating activity and rest periods

Limit self-care activities until symptoms subside

Answer and Explanation

The Correct Answer is C

A.   While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B.   Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C.   Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D.   The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.

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Correct Answer is A

Explanation

A. Dopamine at low doses primarily increases renal perfusion, which can lead to improved urine output. An increase in urine output is a key indicator that the medication is effectively improving kidney function and blood flow. This is the most direct way to assess its effectiveness.
B. A decrease in blood pressure is not an expected effect of low-dose dopamine, which should actually help improve perfusion and raise blood pressure.
C. An increase in heart rate is more likely with higher doses of dopamine and is not an optimal indicator of the drug's effectiveness for acute heart failure.
D. Client alertness is important but does not directly reflect the primary effects of dopamine on renal perfusion and cardiac output in acute heart failure.

A. “I probably will not have any transfusion reactions from my own blood." B. “This is the blood I've been giving for the past 6 weeks for myself. C. "I understand there is still a risk I can get hepatitis from this blood." D. "Since I have O negative blood, it's a good thing I'm getting my own blood."

Correct Answer is C

Explanation

A. “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B. “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C. An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D. “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client diagnosed with acute heart failure is prescribed an infusion of dopamine at a low dose. Which assessment parameter should the nurse use to best evaluate the effectiveness of this medication?

Correct Answer is A

Explanation

The nurse is caring for a client who is to have an autologous transfusion of packed red blood cells. The nurse recognizes the client requires additional teaching when they state:

Correct Answer is C

Explanation

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The nurse is caring for a client who is in the later stages of left-sided heart failure. Which chief complaint would the nurse expect the client to report?

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