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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask family members to remain with the client in the evenings from 1700 to 2100: While family presence can offer comfort, it is not always feasible and doesn’t directly address the environmental management needed for sundowning behaviors.
B. Administer a prescribed PRN benzodiazepine at the onset of a confused state: Though medications may help in acute cases, routine pharmacologic management is not the first-line intervention due to risks like oversedation and increased fall risk in older adults.
C. Postpone administration of nighttime medications until after 2300: Delaying medications may interfere with sleep hygiene and the efficacy of routine medications that aid in rest or symptom management.
D. Ensure that the client is assigned to a room close to the nurses' station: Proximity to staff allows for more frequent monitoring and faster intervention during episodes of confusion, helping prevent injury and manage behaviors associated with sundowning.
Correct Answer is ["A","B","E","G","H"]
Explanation
A. Electrolytes: Electrolytes are important to monitor in this client due to potential blood loss and altered kidney function. Electrolyte imbalances (especially sodium and potassium) can affect heart function, muscle strength, and overall fluid balance, which is crucial after trauma and surgery.
B. Coagulation studies: Given the trauma (liver and spleen lacerations), the client is at risk for bleeding. Coagulation studies (including PT, INR, and aPTT) are necessary to assess the clotting ability and manage bleeding risk, particularly before surgery or when planning for interventions.
C. Blood culture: While blood cultures are important for identifying infections, there is no immediate indication of infection in this patient at this point in time. The priority is stabilizing the patient and managing trauma and bleeding.
D. Lipid panel: A lipid panel is not a priority at this moment. It is generally used to assess cardiovascular risk and would not provide immediate information relevant to managing acute trauma and bleeding.
E. Complete blood count (CBC): A CBC is essential to assess for anemia, infection, or other hematologic abnormalities, especially in trauma patients with possible internal bleeding. Hemoglobin and hematocrit levels provide information about blood loss and oxygen-carrying capacity.
F. Urine osmolality: Urine osmolality is useful for assessing kidney function and hydration but is not immediately necessary in this trauma case. The priority is stabilizing the patient's circulatory and respiratory status, with more focus on urine output and renal function.
G. Arterial blood gas (ABG): An ABG is crucial to assess the client’s oxygenation, ventilation, and acid-base status, especially since the client is intubated and on a ventilator. This will help in monitoring respiratory function and ensuring proper oxygen delivery.
H. Type and screen: The client has a history of trauma and potential internal bleeding. It is essential to know her blood type and ensure compatibility for any potential blood transfusions, particularly before the exploratory laparotomy and any possible further blood loss.
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