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 C

Explanation

Choice A reason: Encouraging the patient to rest in bed for most of the day may lead to further deconditioning and muscle weakness. While rest is important, balancing activity and rest is more beneficial for managing fatigue in chronic anemia.

Choice B reason: Administering a high-protein diet including caffeinated beverages to increase energy levels is not recommended. While a high-protein diet can support energy and muscle strength, caffeine may cause jitteriness and disrupt sleep, which can exacerbate fatigue.

Choice C reason: Assisting the patient with ADLs and encouraging frequent rest periods is appropriate for managing fatigue, weakness, and activity intolerance in chronic anemia. This approach helps the patient conserve energy while maintaining some level of activity to prevent deconditioning.

Choice D reason: Providing supplemental oxygen via face mask during vigorous exercises is not appropriate. Patients with chronic anemia should avoid vigorous exercises that could exacerbate fatigue and weakness. The focus should be on moderate, manageable activities with adequate rest.

A. Fruity-smelling breath B. Sweating and nervousness C. Nausea and vomiting D. Increased thirst and urination

Correct Answer is B

Explanation

Choice A reason: Fruity-smelling breath is a symptom of ketoacidosis, not hypoglycemia. Ketoacidosis occurs when the body produces high levels of ketones due to a lack of insulin, leading to metabolic acidosis.

Choice B reason: Sweating and nervousness are common symptoms of hypoglycemia. Low blood glucose levels trigger the release of adrenaline, which causes these symptoms. Patients should check their blood glucose when experiencing these signs to prevent severe hypoglycemia.

Choice C reason: Nausea and vomiting are more associated with ketoacidosis. High blood glucose levels and the presence of ketones can cause gastrointestinal upset.

Choice D reason: Increased thirst and urination are also symptoms of hyperglycemia and ketoacidosis. These symptoms result from the body's attempt to eliminate excess glucose and ketones through urine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient admitted to the hospital with chronic anemia. The patient reports persistent fatigue, weakness, and activity intolerance. Which intervention will the nurse implement for these manifestations?

Correct Answer is C

Explanation

The nurse is teaching a patient with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. The patient demonstrates understanding of hypoglycemia by stating they will check their blood glucose when experiencing which of the following symptoms?

Correct Answer is B

Explanation

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