Which statement made by a patient indicates a possible exacerbation of heart failure (HF)?

"I have gained 8 pounds this week."

"I am able to breathe easier today."

"I cooked dinner last night."

"There is no swelling in my feet."

Answer and Explanation

The Correct Answer is A

Choice A reason: A rapid weight gain is a common sign of fluid retention, which can indicate an exacerbation of heart failure.

Choice B reason: Being able to breathe easier would typically indicate an improvement in heart failure symptoms, not an exacerbation.

Choice C reason: Cooking dinner suggests a level of activity that is not indicative of an exacerbation of heart failure.

Choice D reason: The absence of swelling in the feet would generally be a positive sign, not indicative of an exacerbation of heart failure.

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Correct Answer is A

Explanation

Choice A reason:Monitoring the apical pulse helps ensure safety and effectiveness of digoxin therapy.

Choice B reason:Offering a light snack is not relevant to digoxin administration.

Choice C reason:While checking the client's blood pressure is important, it is not directly related to digoxin administration.

Choice D reason:Weighing the client is not a specific action related to digoxin administration.

A. Notify the patient's family. B. Provide oxygen as prescribed. C. Notify the health care provider. D. Elevate the head of the bed.

Correct Answer is B

Explanation

Choice A Reason:Notifying the patient's family is not the immediate priority when the patient is experiencing severe respiratory distress. The nurse's primary focus should be on addressing the patient's acute symptoms.

Choice B Reason:Providing oxygen is crucial in managing respiratory distress. In a patient with myocardial infarction (heart attack), adequate oxygenation is essential to prevent further complications. The nurse should promptly administer oxygen as prescribed to improve oxygen supply and alleviate distress.

Choice C Reason:While notifying the health care provider is essential, it is not the first action in this critical situation. The nurse should prioritize interventions that directly address the patient's distress.

Choice D Reason:Elevating the head of the bed (semi-Fowler's position) is beneficial for patients with respiratory distress, but it is not the initial action. Providing oxygen takes precedence over positioning.

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Which statement made by a patient indicates a possible exacerbation of heart failure (HF)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?

Correct Answer is B

Explanation

Which statement regarding the treatment of a myocardial infarction is incorrect?

The nurse would evaluate a female patient, age 68, as understanding teaching on the purpose of coronary artery bypass graft surgery if she made which of the following statements?

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The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

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A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?