A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in bilateral lower extremities. Which action should the nurse take next?

Encourage an increased intake of the client's favorite drink

Continue to monitor daily weights and edema and document findings.

Perform a head-to-toe assessment, including vital signs

Check the record to determine code status

Answer and Explanation

The Correct Answer is C

A. Encouraging increased fluid intake is incorrect. Clients with heart failure are at risk for fluid overload, and excessive fluid intake can worsen symptoms.
B. Simply monitoring and documenting findings is insufficient. A 2-pound weight gain in a short period suggests fluid retention and worsening heart failure, requiring further assessment and possible intervention.
C. Performing a head-to-toe assessment, including vital signs, is correct. The nurse should assess for worsening heart failure, including lung sounds (crackles), respiratory effort, blood pressure, and oxygen saturation, to determine if immediate interventions are needed.
D. Checking code status is not the priority. While knowing a client’s code status is important, the immediate concern is assessing for signs of fluid overload and potential decompensation.

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Correct Answer is A

Explanation

A. "Try taking a mild analgesic to relieve the headache." is correct. Nitroglycerin-induced headaches are a common side effect due to vasodilation. Mild analgesics such as acetaminophen can help alleviate the discomfort.
B. Taking only one dose to reduce the risk of a headache is inappropriate. The client should follow the prescribed dosing regimen to manage angina effectively. Skipping doses may increase the risk of angina attacks.
C. Requesting a different medication is not necessary. Nitroglycerin is an effective treatment for stable angina, and headaches typically diminish over time as the body adjusts to the medication.
D. Stating that nothing can be done to relieve the headaches is incorrect. Headaches from nitroglycerin can be managed with mild analgesics or by adjusting the timing of medication administration.

A. Deep vein thrombosis B. Female C. Obesity D. Atherosclerosis

Correct Answer is C

Explanation

A. Deep vein thrombosis is not a known risk factor for obstructive sleep apnea. Sleep apnea is primarily related to airway obstruction rather than circulatory issues.
B. Being female is incorrect. Obstructive sleep apnea is more common in males than females, although postmenopausal women have an increased risk.
C. Obesity is correct. Excess weight, particularly around the neck, increases the risk of airway obstruction during sleep, making obesity a major risk factor for obstructive sleep apnea.
D. Atherosclerosis is not a direct risk factor. However, untreated obstructive sleep apnea can contribute to cardiovascular issues, including hypertension and atherosclerosis.

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A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in bilateral lower extremities. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's clinic is assessing a client who takes sublingual nitroglycerin for stable angina. The client reports getting a headache each time he takes the medication. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

The nurse recognizes which of the following as a risk factor for obstructive sleep apnea?

Correct Answer is C

Explanation

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