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 B
Explanation
A. Nitroglycerin is used in the acute phase of an MI to relieve chest pain by dilating coronary arteries. However, after the initial phase, it is not the primary medication for managing pain and anxiety.
B. Morphine is administered after the initial acute phase to manage pain and anxiety. It reduces myocardial oxygen demand, decreases pain perception, and provides sedation, which can help lower stress levels.
C. Aspirin is given in the acute phase to prevent further clot formation but does not address pain and anxiety.
D. Oxygen is administered in the acute phase if the client is hypoxic, but routine oxygen therapy is no longer recommended unless needed.
Correct Answer is ["C","D","E"]
Explanation
A. Ascites is more commonly associated with right-sided heart failure. Right-sided failure leads to systemic congestion, causing fluid accumulation in the abdomen.
B. Edema in the legs and feet is a symptom of right-sided heart failure. Left-sided failure primarily affects the lungs, while right-sided failure leads to peripheral edema.
C. Crackles in the lungs are expected in left-sided heart failure. Pulmonary congestion results from blood backing up into the lungs, leading to fluid accumulation in the alveoli.
D. Confusion can occur due to decreased cardiac output and poor oxygenation to the brain. Clients with severe heart failure may experience cognitive changes or altered mental status.
E. Exertional dyspnea is a hallmark of left-sided heart failure. The inability of the left ventricle to pump effectively leads to pulmonary congestion, making breathing difficult during physical activity.
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