What is the best indication if the client with congestive heart failure is holding excess fluid?

Intake and output

Pitting pedal edema

Crackles in the bases of the lungs

Daily weights

Answer and Explanation

The Correct Answer is D

A. Intake and output:

Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.

B. Pitting pedal edema:

Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.

C. Crackles in the bases of the lungs:

Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.

D. Daily weights:

Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Obtain a sputum sample:

This option is more relevant when the client is experiencing cough with sputum production, which might suggest respiratory issues. However, in the context of coughing after eating or drinking, the primary concern is likely related to the swallowing process rather than respiratory conditions.

B. Inspect the client’s tongue and mouth:

While inspecting the tongue and mouth is a good practice for assessing oral health, it may not directly address the issue of coughing after eating or drinking, which is more indicative of potential swallowing difficulties.

C. Perform a swallowing assessment:

This is the most appropriate option for the given scenario. A swallowing assessment helps identify any abnormalities or difficulties in the swallowing process, which could contribute to the client's coughing after eating or drinking.

D. Assess the client’s nutritional status:

While assessing nutritional status is important for overall health, it may not directly address the immediate concern of coughing after eating or drinking. Nutritional status assessment is a broader aspect of care.

Correct Answer is ["4"]

Explanation

Warfarin (Coumadin) is an anticoagulant medication that prevents blood clots from forming or growing larger. It is prescribed for clients who have atrial fibrillation, deep vein thrombosis, pulmonary embolism, or artificial heart valves.

The physician orders warfarin 10 mg PO to be administered to a client at 1800 today. The pharmacy only has 2.5 mg tablets available. To calculate the number of tablets that the nurse will administer, the nurse will divide the ordered dose by the available dose. The formula is:

Number of tablets = Ordered dose / Available dose

Number of tablets = 10 mg / 2.5 mg

Number of tablets = 4

Therefore, the nurse will administer 4 tablets of warfarin 2.5 mg PO to the client at 1800 today

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What is the best indication if the client with congestive heart failure is holding excess fluid?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up on this assessment finding?

Correct Answer is C

Explanation

The physician orders warfarin (Coumadin) 10 mg PO to be administered to a client at 1800 today. The pharmacy only has 2.5 mg tablets available. How many tablets will the nurse administer?

Correct Answer is ["4"]

Explanation

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)

A client is ordered to receive atropine 0.3 mg IV stat. Atropine 0.4 mg per mL is available. How many milliliters will the nurse administer?

The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what antidote?

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

The nurse is taking health history for a client who reports pain in his lower left leg and foot when walking. The pain is relieved with rest, and the nurse observes the left leg is hairless and slightly edematous. The nurse recognizes this as which medical diagnosis or health problem?

The nursing student is reviewing interventions which are part of nursing care and prevention of atelectasis. What are some of the interventions nurses can do to prevent atelectasis? (SELECT ALL THAT APPLY)

A nurse assesses a client’s respiratory status. Which observation indicates that the client is having difficulty breathing?