Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

Heart rate 100 beats per minute

+ 3 peripheral edema

Respiratory rate of 24 at rest

Alert and oriented X 3

Answer and Explanation

The Correct Answer is D

A.   A heart rate of 100 beats per minute is considered tachycardia (a heart rate above 100 bpm). This is not an indicator of improvement in heart failure, as it suggests the heart is working harder than usual. Chronic heart failure can lead to compensatory mechanisms such as tachycardia, but it’s typically not a sign of improvement.
B.   Peripheral edema (swelling in the legs, ankles, or feet) is a common symptom of heart failure, resulting from fluid buildup due to poor cardiac output. A rating of +3 edema indicates moderate to severe swelling, which suggests fluid retention and poor circulation. This is a sign of worsening or poorly controlled heart failure, not improvement.
C.   A respiratory rate of 24 breaths per minute is slightly elevated, as the normal resting respiratory rate for adults is typically between 12 to 20 breaths per minute. A higher respiratory rate can be a sign of respiratory distress or compensatory breathing due to insufficient oxygenation or fluid buildup in the lungs (pulmonary edema), which are both symptoms of heart failure exacerbation.
D.   Being alert and oriented X 3 means the client is aware of time, place, and person, indicating no signs of confusion or cognitive impairment. In the context of chronic heart failure, mental status changes (like confusion or disorientation) can occur due to decreased cerebral perfusion, low oxygen levels, or medications (such as diuretics or digitalis.

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Correct Answer is C

Explanation

A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.

Correct Answer is ["11"]

Explanation

The patient weighs 121 lbs, which is approximately 55 kilograms (121 ÷ 2.2).

Next, multiply the patient's weight in kilograms by the dosage prescribed, which is 20 units/kg. This results in a total dosage of 1100 units (55 kg × 20 units/kg).

The medication is supplied as 25,000 units in 250 mL, so to find out how many mL of medication is needed, set up a proportion: 25,000 units is to 250 mL as 1100 units is to X mL. Solving for X gives you 11 mL (1100 units × 250 mL ÷ 25,000 units).

Therefore, the nurse will administer 11 mL of Heparin to the patient.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

Which clinical manifestation would the nurse use to best indicate that the status of an elderly client's chronic heart failure condition is Improving?

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Naxlex Comprehensive Predictor Exams

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

Correct Answer is C

Explanation

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 121 Ibs. The medication is supplied as 25,000 units/250 mL. How many Ml will the nurse give? (round to the nearest whole number)

Correct Answer is ["11"]

Explanation

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