A client has been diagnosed with heart failure. One of the main overall objectives of the management of heart failure is which of the following?

Achieve a blood pressure of 120/80

Reduce the workload on the heart

Help the client walk briskly on a treadmill at 4 to 5 miles an hour

Eliminate all sodium and fat from the diet

Answer and Explanation

The Correct Answer is B

Choice A reason : Achieving a blood pressure of 120/80 is a general goal for overall cardiovascular health, but it is not specific to the management of heart failure. While controlling blood pressure is important in heart failure, the primary objective is to reduce the heart's workload¹.

Choice B reason : Reducing the workload on the heart is a key objective in managing heart failure. This can be achieved through medications that improve heart function, lifestyle changes, and sometimes surgical interventions. The goal is to improve the heart's efficiency and reduce symptoms such as shortness of breath and fatigue¹.

Choice C reason : Encouraging the client to walk briskly on a treadmill at 4 to 5 miles an hour may not be appropriate for all heart failure patients, especially without medical supervision. Exercise recommendations should be personalized based on the individual's condition and tolerance¹.

Choice D reason : While dietary modifications are part of heart failure management, completely eliminating all sodium and fat is not practical or recommended. Instead, a balanced diet with controlled sodium intake is advised to help manage fluid retention¹.

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Correct Answer is B

Explanation

Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.

Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.

Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.

Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².

A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Educating the client about the consequences of alcohol misuse D. Confronting the use of denial and other defense mechanisms

Correct Answer is B

Explanation

Choice A reason : While helping the client identify positive personality traits can be beneficial for self-esteem and long-term recovery, it is not the immediate priority during the acute withdrawal phase. The focus during this time should be on managing withdrawal symptoms and ensuring the client's safety¹.

Choice B reason : Providing for adequate hydration and rest is the priority intervention for a client in alcohol withdrawal. Withdrawal can lead to significant fluid loss due to vomiting and sweating, and rest is essential for the body to recover from the physiological stress of detoxification. Ensuring the client is well-hydrated and rested can prevent complications and aid in the recovery process¹².

Choice C reason : Educating the client about the consequences of alcohol misuse is an important part of treatment but is not the immediate priority during withdrawal. Education is more effective when the client is stable and can participate actively in learning and discussion¹.

Choice D reason : Confronting the use of denial and other defense mechanisms may be part of the therapeutic process but is not the immediate priority during the acute phase of withdrawal. The nurse's immediate concern should be the physical stabilization of the client¹.

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A client has been diagnosed with heart failure. One of the main overall objectives of the management of heart failure is which of the following?

Nursing Test Bank

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