A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Provide a bedside commode for toileting.

Assist with ambulation in the hallway.

Teach to sleep in a side-lying position.

Encourage active range of motion exercises.

Answer and Explanation

The Correct Answer is A

A. Provide a bedside commode for toileting: This intervention helps reduce the cardiac workload by minimizing the effort needed for the client to walk to the bathroom. It allows the client to conserve energy and reduce the strain on the heart.

B. Assist with ambulation in the hallway: While mobility is important, ambulating in the hallway can increase the heart’s workload, especially in a client with heart failure and pneumonia. It's best to minimize unnecessary physical exertion to prevent exacerbations.

C. Teach to sleep in a side-lying position: While side-lying can sometimes help with breathing, this position does not directly reduce the cardiac workload. The priority is ensuring the client has adequate rest and minimizing physical strain.

D. Encourage active range of motion exercises: While range of motion exercises are important for preventing complications like muscle atrophy, they may increase the cardiac workload. For a client with pneumonia and heart failure, the priority is to reduce exertion and conserve energy.

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Correct Answer is C

Explanation

A. Type of anticonvulsant prescribed: While the class or type of anticonvulsant influences seizure control, it does not directly indicate whether the client is receiving a sufficient dosage. The therapeutic effectiveness depends more on blood concentration than classification.

B. History of a recent illness: Acute illness can temporarily lower the seizure threshold, but it is a less specific indicator for predicting recurrence than pharmacologic control. The underlying condition must be assessed, but medication levels are more predictive of seizure risk.

C. Therapeutic level of medication: A subtherapeutic drug level is a strong predictor of seizure recurrence. Maintaining an adequate plasma concentration ensures optimal seizure control and is crucial in clients recovering from status epilepticus, where precise management is essential.

D. Duration of previous seizure activity: The length of the prior seizure can indicate severity but not the likelihood of recurrence. Even brief seizures can recur if anticonvulsant levels are inadequate, so duration is not as clinically useful as drug level monitoring.

A. Suggest to the client that he take a walk. B. Use firmness and direct the client to sit for a while. C. Move the client to a quiet place on the unit. D. Encourage the client to use the punching bag.

Correct Answer is C

Explanation

A. Suggest to the client that he take a walk: Allowing pacing might escalate the agitation or delusions, especially in a stimulating environment. This does not address the immediate need to reduce stimuli.

B. Use firmness and direct the client to sit for a while: Direct commands may increase the client's agitation or trigger a confrontation if the client feels threatened or challenged while delusional.

C. Move the client to a quiet place on the unit: Reducing environmental stimuli by relocating the client to a low-stimulation setting can help de-escalate the situation and prevent further loss of control.

D. Encourage the client to use the punching bag: Promoting physical aggression even if directed at an object may reinforce violent behavior and is inappropriate during acute delusional episodes.

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A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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