The nursing students are preparing a care plan for a patient with heart failure. The patient will be prescribed diuretic therapy after discharge. What evidence-based instructions will the nurse include in this plan?
Potassium supplements can cause irregular heart rhythm and must be avoided.
Instruct the patient to take diuretics at bedtime to promote diuresis during the night.
Notify the physician if weight increases by three pounds in one week.
Administer diuretics in the morning and notify physician of decreased urine output.
The Correct Answer is C
Choice A reason: Potassium supplements can actually be important for patients on diuretic therapy, especially if they are taking loop diuretics like furosemide, which can cause potassium loss. However, it is important to monitor potassium levels and follow the physician's guidance on supplement use.
Choice B reason: Instructing the patient to take diuretics at bedtime is not recommended. Diuretics should be taken in the morning to avoid frequent urination during the night, which can disrupt sleep.
Choice C reason: Notifying the physician if weight increases by three pounds in one week is a key instruction for patients with heart failure. Rapid weight gain can indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and adjustment of treatment.
Choice D reason: Administering diuretics in the morning and notifying the physician of decreased urine output is important, but the focus on notifying the physician about significant weight gain provides a more specific and actionable guideline for managing heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Candidiasis, or oral thrush, is a common side effect of inhaled corticosteroids like budesonide. Patients should be educated on the importance of rinsing their mouth after using the inhaler to reduce the risk of this fungal infection.
Choice B reason: Dysphonia, or hoarseness, is another potential side effect of budesonide inhalers. This occurs due to the medication's effect on the vocal cords and can be minimized by using a spacer and rinsing the mouth after inhalation.
Choice C reason: Weight loss is not a common side effect of inhaled budesonide. Inhaled corticosteroids typically do not affect body weight in the same way that systemic corticosteroids might.
Choice D reason: Headache is a potential side effect of budesonide inhalers. Patients should be informed about this possibility and advised to manage headaches with appropriate over-the-counter medications if needed.
Correct Answer is B
Explanation
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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