A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

The client’s oxygen saturation level is 85%.

The client is eating less than half of meals

The client’s heart rate is 110 beats per minute.

The client is reading a book.

The client’s blood pressure is 160/90 mmHg.

Answer and Explanation

Correct Answer : A,C,E

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

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 B

Explanation

Choice A rationale:

“I should take this medication with food to prevent stomach upset.” Rationale: This statement is not accurate for fluconazole. While some medications should be taken with food to reduce stomach upset, fluconazole is typically taken on an empty stomach. Taking it with food may reduce its absorption.

Choice B rationale:

“I should avoid drinking alcohol while taking this medication.” Rationale: This is the correct response. Fluconazole can interact with alcohol and may lead to increased side effects or reduced effectiveness of the medication. Therefore, it is essential to avoid alcohol while taking fluconazole.

Choice C rationale:

“I should use a barrier method of contraception while taking this medication.” Rationale: While it is generally a good practice to use barrier contraception during treatment for a fungal infection to prevent potential spread to a partner, this statement does not specifically address fluconazole's requirements or interactions.

Choice D rationale:

“I should stop taking this medication if I develop a rash.” Rationale: This statement is not entirely accurate. While it is important to monitor for skin rashes as they can be a sign of an allergic reaction, the decision to stop taking fluconazole should be made in consultation with a healthcare provider. It is not an automatic response to developing a rash.

A. Decreasing gastrointestinal (GI) cramping and nausea. B. Chest pain and dysrhythmia. C. Vasodilation of the extremities. D. Hypotension and tachycardia.

Correct Answer is B

Explanation

The correct answer is B

Choice A reason: Vasopressin is not typically associated with decreasing GI cramping and nausea. It is used to treat diabetes insipidus and to reduce stomach bloat for some procedures and after some surgeries.

Choice B reason: Vasopressin can cause chest pain or pressure, and fast, slow, or abnormal heartbeat, which are indicative of dysrhythmia. These are known side effects of vasopressin and should be monitored during IV infusion.

Choice C reason: Vasopressin causes vasoconstriction, not vasodilation. It tightens small blood vessels, which is the opposite of vasodilation.

Choice D reason: While vasopressin can cause bradycardia (slow heart rate), hypotension is not a common effect as it is used to treat low blood pressure. Tachycardia (fast heart rate) is not a typical side effect of vasopressin.

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

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

Correct Answer is B

Explanation

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

A client who has atrial fibrillation is prescribed warfarin therapy. Which of the following statements by the client indicates an understanding of the medication?

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching?