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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Procure platelet products from the blood bank: UAPs may be delegated non-invasive tasks such as transporting lab specimens or retrieving blood products. This task does not require nursing judgment and is appropriate for delegation under routine supervision.
B. Titrate oxygen to the prescribed parameters: Titrating oxygen requires assessment and clinical judgment, as adjustments depend on vital signs and client condition. This is within the RN or LPN scope, not the UAP’s, due to the potential for rapid status changes.
C. Insert a urinary catheter for an uncomplicated client: Insertion of catheters is an invasive procedure that requires sterile technique and knowledge of anatomy. This task must be performed by a licensed nurse, not a UAP, even in uncomplicated cases.
D. Monitor an IV infusion rate on an established schedule: Although observation is within the UAP role, monitoring IV infusions involves understanding flow rates, recognizing signs of infiltration or complications, and making clinical decisions, all of which exceed UAP scope.
Correct Answer is B
Explanation
A. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: There are no cures for Parkinson's disease, and suggesting that alternative treatments could cure it could create unrealistic expectations.
B. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: This response provides accurate information while being honest about the limitations of current treatments for Parkinson's disease.
C. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or conventional medications currently cure Parkinson’s disease. The nurse should avoid suggesting potential cures that are not based on scientific evidence.
D. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While this may be supportive for the wife, it does not directly address her question about treatment options. The focus should be on providing accurate information regarding the disease and treatment options.
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