The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).
Consume 2500mL of fluids per day during the summer months
Maintain daily sodium intake of no more than 2gm per day
Notify the health care provider if weight increases by 5 Ibs. in one week
If shortness of breath occurs with minimal activity, notify the provider
Take furosemide anytime when feeling bloated or short of breath
Correct Answer : B,C,D
A. Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B. A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C. Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D. Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E. Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A decreased D-dimer level is a positive outcome, as D-dimer is elevated in DIC due to the formation of clots and the breakdown of fibrin. Lower levels indicate less clot formation and better control of the condition.
B. Fibrinogen levels are typically low in DIC due to consumption of clotting factors. Elevated fibrinogen in this case would be a negative indicator, suggesting that clotting is not resolving.
C. A decreased platelet count is a hallmark of DIC and indicates ongoing consumption of platelets due to widespread clotting. A decrease would not be a positive outcome.
D. A prolonged PT is another indicator of DIC, suggesting impaired clotting function. This is not a positive outcome.
Correct Answer is A
Explanation
A. Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B. Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C. Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D. Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.
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