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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A pulmonary function test is used to assess lung diseases like COPD or asthma. It is not the primary diagnostic test for fluid overload and heart failure.
B. Alpha-1 antitrypsin deficiency is associated with early-onset COPD, but it does not relate to symptoms of fluid retention and heart failure as described in the question.
C. Brain Natriuretic Peptide (BNP) is correct. BNP is released when the ventricles stretch due to fluid overload, making it a key diagnostic marker for heart failure. Elevated BNP levels indicate increased cardiac filling pressures and volume overload, which match the client’s symptoms.
D. A Doppler ultrasound is useful for detecting deep vein thrombosis (DVT) or vascular issues, but it does not assess systemic fluid retention and heart failure.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
- Obtain intravenous (IV) access: IV access is necessary for administering medications, fluids, and emergency interventions.
- Obtain the client's family history: While family history is important for long-term cardiac risk assessment, it is not a priority in the acute phase of chest pain management.
- Apply continuous ECG monitoring: Continuous ECG monitoring is critical for detecting arrhythmias, ischemic changes, and potential myocardial infarction (MI).
- Administer O₂ to maintain oxygen saturation greater than 90%: Oxygen therapy is indicated in clients with suspected MI if their oxygen saturation is below 90% to prevent further myocardial ischemia.
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