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.

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Correct Answer is B

Explanation

A. To ensure long-term prevention of asthma exacerbations:

This statement is not accurate. Prednisone is typically not used for long-term prevention of asthma exacerbations. It is more commonly prescribed for short-term use during acute exacerbations to quickly reduce inflammation and improve symptoms.

B. To gain control of inadequately controlled, persistent asthma:

This is the most accurate explanation. Prednisone is often prescribed to gain control over inadequately controlled, persistent asthma by providing anti-inflammatory effects and helping to manage symptoms during acute episodes.

C. To cure any systemic infection underlying asthma attacks:

Prednisone is not used to cure infections. While it can have anti-inflammatory and immunosuppressive effects, its primary role in asthma is to reduce airway inflammation and control symptoms, not to treat underlying infections.

D. To prevent recurrent pulmonary infections:

Prednisone is not typically prescribed for the prevention of infections. Its use in asthma is more focused on managing inflammation and symptoms during acute exacerbations rather than preventing infections.

A. Administer antibiotics B. Encourage increased oral fluid intake C. Early mobilization after surgery D. Frequent turning of the patient E. Use of incentive spirometry

Correct Answer is ["B","C","D","E"]

Explanation

A. Administer antibiotics

Administering antibiotics is not a direct intervention for preventing atelectasis. Antibiotics are typically prescribed to treat bacterial infections, and atelectasis is more related to lung collapse or incomplete lung expansion.

B. Encourage increased oral fluid intake

Adequate hydration is important for maintaining the moisture of respiratory secretions. This helps prevent mucus from becoming thick and sticky, making it easier for the patient to cough and clear the airways.

C. Early mobilization after surgery

Early mobilization, including activities such as getting out of bed and walking, helps improve lung expansion. It promotes better ventilation and prevents areas of the lungs from collapsing, reducing the risk of atelectasis.

D. Frequent turning of the patient

Turning the patient regularly is crucial for preventing pooling of respiratory secretions in dependent areas of the lungs. By changing the patient's position, nurses can facilitate drainage and ventilation throughout the lungs, minimizing the risk of atelectasis.

E. Use of incentive spirometry

Incentive spirometry is a breathing exercise device that encourages the patient to take slow, deep breaths. This helps expand the lungs and prevents atelectasis by maintaining lung volume and promoting alveolar recruitment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is explaining to a client with asthma what her new prescription for prednisone, a systemic corticosterioid, is used for in the treatment of asthma. What would be the most accurate explanation that the nurse could give?

Correct Answer is B

Explanation

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)

Correct Answer is ["B","C","D","E"]

Explanation

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