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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Delivering a continuous flow of air pressure to keep the airway open is correct. CPAP (Continuous Positive Airway Pressure) prevents airway collapse during sleep, allowing for uninterrupted breathing and oxygenation.
B. Reducing daytime sleepiness is a benefit of CPAP use, but it is not its primary purpose—it is a secondary effect of improved oxygenation and sleep continuity.
C. Improving sleep quality also occurs with CPAP therapy, but this is an outcome rather than the primary purpose.
D. Promoting weight loss is not the function of CPAP therapy, though weight loss can help reduce OSA severity.
Correct Answer is A
Explanation
A. Headache is correct. Clients with obstructive sleep apnea often experience morning headaches due to intermittent hypoxia and hypercapnia caused by repeated episodes of airway obstruction during sleep.
B. Hypotension is incorrect. Obstructive sleep apnea is more commonly associated with hypertension rather than hypotension due to the body's stress response to low oxygen levels.
C. Constipation is not a common symptom of obstructive sleep apnea. Gastrointestinal symptoms are not typically associated with this condition.
D. Nausea is not a characteristic finding in obstructive sleep apnea. The primary symptoms involve respiratory and neurological effects due to oxygen deprivation during sleep.
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