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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.

B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.

C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.

D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.

A. Electrolytes B. Coagulation studies C. Blood culture D. Lipid panel E. Complete blood count F. Urine osmolality G. Arterial blood gas H. Type and screen

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is C

Explanation

Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

Correct Answer is ["A","B","E","G","H"]

Explanation

The healthcare provider prescribes dalteparin 200 units/kg SUBQ once a day for a client who weighs 154 lb. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Exhibits The client asks the diabetic nurse educator to clarify what the Registered Dietician told her about the content and timing of her meals. Which 3 responses should the diabetic nurse educator provide?