A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Weigh every morning.

Perform range of motion exercises.

Limit fluid intake to 1,500 mL daily.

Eat a high protein diet.

Answer and Explanation

The Correct Answer is A

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

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Correct Answer is A

Explanation

Allen's test is a procedure used to assess the patency of the ulnar artery and the collateral circulation of the hand. It is performed to determine the adequacy of collateral circulation before obtaining arterial blood gases from the radial artery. The test helps ensure that the ulnar artery is functioning properly and can supply blood to the hand if the radial artery is used for blood sampling or other invasive procedures.

The test involves occluding both the ulnar and radial arteries while the patient clenches their fist. The nurse then releases pressure on the ulnar artery while maintaining occlusion of the radial artery. The hand should quickly regain normal coloration, indicating adequate collateral circulation.
It's important to note that the Allen's test is specific to the assessment of collateral circulation in the hand and is not used for other purposes such as assessing deep vein thrombosis, cardiac output calculation, or obtaining pulmonary artery pressures.

A. Correct dosage of medication B. Vital signs with SaO2 C. Pain report from parent D. Valid pain assessment tool E. Identify allergies F. Subjective pain assessment

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

Explanation

It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.

Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.

Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.

It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.

Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.

Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.

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A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

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Naxlex Comprehensive Predictor Exams

When should the nurse conduct an Allen's test?

Correct Answer is A

Explanation

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

Explanation

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