The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Weigh patient using bed scale and restrict oral fluids.

Obtain pulse oximetry levels and assess the respiratory status.

Elevate lower extremity on two pillows while patient is in bed.

Obtain a Physical Therapy consultation to evaluate activity tolerance.

Answer and Explanation

The Correct Answer is B

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

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Correct Answer is B

Explanation

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

A. "I will adhere to my medication regimen even when I am not experiencing symptoms." B. "I will maintain regular physical activity and exercise with planned rest periods." C. "I will soak in a hot bath every night to help with muscle weakness and fatigue." D. "I will identify strategies to control anxiety and physical stress to prevent exacerbations."

Correct Answer is C

Explanation

Choice A reason: Adhering to the medication regimen even when not experiencing symptoms is crucial for managing multiple sclerosis (MS). MS is a chronic condition that requires consistent treatment to prevent relapses and slow disease progression. This statement indicates proper understanding of medication adherence.

Choice B reason: Maintaining regular physical activity and exercise with planned rest periods is important for managing MS. Physical activity helps maintain muscle strength, flexibility, and overall health, while planned rest periods prevent overexertion and fatigue. This statement indicates proper understanding of balancing activity and rest.

Choice C reason: Soaking in a hot bath every night to help with muscle weakness and fatigue requires further teaching. Heat can exacerbate MS symptoms, leading to increased fatigue and muscle weakness. Patients with MS are often advised to avoid hot baths and instead use cool or lukewarm water for comfort. This statement indicates a misunderstanding of how to manage symptoms effectively.

Choice D reason: Identifying strategies to control anxiety and physical stress to prevent exacerbations is important for managing MS. Stress can trigger MS relapses and worsen symptoms. Developing stress management techniques helps reduce the risk of exacerbations. This statement indicates proper understanding of the importance of stress management.

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The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

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Naxlex Comprehensive Predictor Exams

The nurse assesses a patient 20 minutes after initiating a blood transfusion. The patient has itching and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What intervention will the nurse prioritize to implement first for this patient?

Correct Answer is B

Explanation

The nurse is teaching a patient with a new diagnosis of multiple sclerosis (MS) about self-care with this condition. What patient statement indicates to the nurse that the patient requires further teaching?

Correct Answer is C

Explanation

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