The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. Which of the following statements by the client requires additional teaching?

I will weigh myself daily and notify the healthcare provider if I gain 3 pounds in one day.

I will notify the healthcare provider if I am becoming increasingly short of breath at rest.

I will include lower sodium intake in my daily diet.

I understand that I may need to sleep sitting up in a reclining chair.

Answer and Explanation

The Correct Answer is D

Choice A reason: Daily weight monitoring and reporting a 3-pound gain in one day indicates fluid retention, a sign of worsening heart failure. This is correct and shows understanding of self-monitoring to prevent complications, requiring no further teaching.

Choice B reason: Notifying the provider about increasing shortness of breath at rest is appropriate, as it signals worsening heart failure due to reduced cardiac output or pulmonary edema. This reflects proper understanding of symptom monitoring, requiring no additional teaching.

Choice C reason: A low-sodium diet reduces fluid retention in heart failure by decreasing sodium-induced water retention, preventing worsening of edema or congestion. This statement is correct and demonstrates understanding of dietary management, requiring no further teaching.

Choice D reason: Sleeping in a reclining chair may occur in severe heart failure due to orthopnea, but it is not a standard recommendation. It suggests poor symptom control, requiring further teaching on optimizing medical management, such as medication adherence and fluid monitoring, to prevent this need.

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Correct Answer is D

Explanation

Choice A reason: Resuming vigorous activity like tennis one week post-pacemaker insertion risks lead dislodgement, as the device requires time to stabilize. Arm movements in tennis, especially overhead swings, can disrupt the pacemaker leads, making this advice unsafe and inappropriate.

Choice B reason: Suggesting hockey or skating as alternatives is incorrect, as these activities also involve significant physical exertion and risk of trauma to the pacemaker site. Additionally, delaying until fall is arbitrary, and these sports do not reduce the risk of lead dislodgement compared to tennis.

Choice C reason: Substituting tennis with basketball or football is inappropriate, as these contact sports pose a higher risk of trauma to the pacemaker site, potentially causing device malfunction or lead dislodgement. These activities are not safer alternatives and could exacerbate complications.

Choice D reason: Restricting arm movement above the head for two weeks post-pacemaker insertion prevents lead dislodgement, as the leads need time to anchor in the heart tissue. Tennis involves vigorous arm motions, so canceling the tournament is necessary to ensure device stability and client safety.

A. Administer furosemide (Lasix) 80 mg IV as ordered B. Administer a thrombolytic medication C. Prepare for transcutaneous pacing D. Prepare for synchronized cardioversion

Correct Answer is C

Explanation

Choice A reason: Furosemide is a diuretic used for fluid overload in heart failure, not for second-degree AV block Type II, which causes bradycardia and hypotension. Administering it could worsen hypotension by reducing preload, making it inappropriate for this client’s acute conduction issue.

Choice B reason: Thrombolytic medications are used for acute myocardial infarction or stroke to dissolve clots. Second-degree AV block Type II is a conduction disorder, not a thrombotic event, so thrombolytics are irrelevant and could cause harmful bleeding in this scenario.

Choice C reason: Second-degree AV block Type II causes intermittent failure of atrial impulses to conduct, leading to bradycardia and hypotension. Transcutaneous pacing restores heart rate and cardiac output, stabilizing the client’s hemodynamics, making it the most appropriate intervention for this life-threatening rhythm disturbance.

Choice D reason: Synchronized cardioversion is used for tachyarrhythmias like atrial fibrillation or ventricular tachycardia. Second-degree AV block Type II is a bradyarrhythmia, so cardioversion is inappropriate. Pacing is needed to increase heart rate and address the client’s symptoms effectively.

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The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. Which of the following statements by the client requires additional teaching?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in one week. What teaching should the nurse provide to the client related to this activity?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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