A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure.
Which of the following is the priority topic for the nurse to review with the client?
Daily exercise routine.
Daily sodium restrictions.
Fluid intake record.
Changes in weight.
The Correct Answer is D
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This can help prevent dizziness and loss of balance, which are common symptoms of Ménière’s disease.
Choice B is not correct because range-of-motion exercises to the client’s neck every 4 hours are not a standard intervention for Ménière’s disease.
Choice C is not correct because aspirin is not always the recommended medication for headaches associated with Ménière’s disease.
Choice D is not correct because limiting fluid intake is not a standard intervention for Ménière’s disease.
Correct Answer is C
Explanation
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
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