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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb) since the last visit 2 days ago. Which of the following actions should the nurse take first?

Teach the client about foods low in sodium.

Encourage the client to dangle the legs while sitting in a chair.

Determine medication adherence by the client.

Notify the provider of the client's weight gain.

Answer and Explanation

The Correct Answer is D

A. Teaching about sodium is important but not an immediate action in response to weight gain.

B. Dangling the legs can help reduce edema but does not address the underlying cause of fluid retention.

C. Determining medication adherence is helpful but is secondary to addressing the acute concern of fluid retention.

D. Notifying the provider is the priority action. A 5 lb weight gain in 2 days may indicate fluid retention and worsening heart failure, requiring immediate intervention from the provider.

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Correct Answer is C

Explanation

A. Output above 30 mL/hr is acceptable and not concerning.

B. A BP of 122/88 is within normal limits.

C. A decrease in deep tendon reflexes (DTRs), such as 1+, can indicate magnesium toxicity and requires immediate intervention.

D. Normal pupillary findings do not indicate toxicity.

A. Administers the injection in the abdomen B. Aspirates the medication after injection C. Massages the site to enhance absorption D. Releases the skin fold before injecting the medication

Correct Answer is A

Explanation

A. Enoxaparin should be administered subcutaneously in the abdomen at least 2 inches from the umbilicus.

B. Aspiration is not recommended for subcutaneous injections, especially anticoagulants.

C. Massaging the site is contraindicated because it can increase the risk of bruising and tissue damage.

D. The skin fold should be maintained during injection to ensure proper subcutaneous delivery.

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A home health nurse is visiting a client who has heart failure and a prescription for furosemide. The nurse identifies that the client has gained 2.5 kg (5 lb) since the last visit 2 days ago. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving IV magnesium sulfate for treatment of preeclampsia. Which of the following findings should the nurse report?

Correct Answer is C

Explanation

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Correct Answer is A

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