A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Document the findings and continue with the visit.
Notify the RN case manager of the change in status.
Reinforce the importance of daily weights.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is B
A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.
B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.
C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.
D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.
Correct Answer is A
Explanation
A. A heart rate of 56/min indicates bradycardia, which can reduce cardiac output and lead to dizziness due to decreased cerebral perfusion.
B. A high temperature is not directly associated with bradycardia; fever typically causes tachycardia.
C. Hypoglycemia does not have a direct relationship with bradycardia; it is more commonly associated with symptoms like sweating, confusion, and tremors.
D. Cigarette smoking typically contributes to conditions like tachycardia and vascular constriction, not bradycardia.
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