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 C
Explanation
A. Having the client lay flat for 4 hours is appropriate. After coronary angiography, bed rest is required to prevent bleeding from the arterial puncture site, especially if a femoral approach was used.
B. Monitoring the site for bleeding and hematoma formation is correct. Bleeding is a potential complication, and frequent assessment of the catheter insertion site is necessary.
C. Administering metformin should be questioned. Metformin is contraindicated within 48 hours of receiving contrast dye because of the risk of lactic acidosis, especially in clients with impaired renal function.
D. Administering aspirin is appropriate. Aspirin is commonly prescribed to prevent clot formation after a coronary procedure.
Correct Answer is A
Explanation
A. Weight loss is not a common side effect of prednisone. Instead, prednisone often causes weight gain due to fluid retention and increased appetite.
B. Dry mouth can occur with prednisone use, although it is less common than other side effects.
C. Hyperglycemia is a common side effect. Corticosteroids like prednisone can increase blood glucose levels, which is particularly concerning for clients with diabetes.
D. Decreased wound healing is a known side effect. Prednisone suppresses the immune system and inflammatory response, leading to delayed tissue repair.
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