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?
Determine medication adherence by the client.
Teach the client about foods low in sodium.
Encourage the client to dangle the legs while sitting in a chair.
Notify the provider of the client's weight gain.
The Correct Answer is D
A. Determine medication adherence by the client:
This choice is incorrect as the nurse should first take immediate actions to address the client's weight gain and potential exacerbation of heart failure symptoms. While medication adherence is important, it's not the first action to take in this situation.
B. Teach the client about foods low in sodium:
This choice is incorrect as educating the client about sodium intake is important for managing heart failure, but the priority in this case is to address the current weight gain and potential worsening of the client's condition.
C. Encourage the client to dangle the legs while sitting in a chair:
This choice is incorrect. Dangling the legs while sitting in a chair can help improve blood circulation in some cases, but it's not the first action to take when the client has gained a significant amount of weight since the last visit. The priority should be addressing the weight gain and its potential impact on the client's heart failure.
D. Notify the provider of the client's weight gain:
This is the correct choice. When a client with heart failure experiences a sudden weight gain, it can indicate fluid retention and worsening of their condition. Notifying the healthcare provider about the weight gain is crucial to ensure timely assessment, potential medication adjustments, and other interventions to prevent further deterioration of the client's health. Prompt communication with the provider can help prevent complications associated with heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client has a negative sputum culture.
When a client with tuberculosis is adhering to the prescribed medication regimen, their sputum cultures should show a decrease in the number of Mycobacterium tuberculosis bacteria. This indicates that the medication is effectively treating the infection. It's important for clients with tuberculosis to complete their full course of treatment to prevent drug-resistant strains of the bacteria from developing.
B. The client tests negative for HIV: This relates to a different infection (HIV) and doesn't necessarily reflect adherence to the tuberculosis medication regimen.
C. The client's liver function test results are within the expected reference range: While liver function tests are important to monitor due to potential medication side effects, they don't directly indicate medication adherence.
D. The client has a positive purified protein derivative (PPD) test: A positive PPD test indicates exposure to the tuberculosis bacteria in the past but does not reflect current adherence to treatment.
Correct Answer is A
Explanation
A. For assessing pain in a 4-year-old child following an orthopedic procedure, the nurse should use the FACES pain scale.
The FACES pain scale uses a series of faces with varying expressions, from smiling to crying, to help children express their level of pain. Children are asked to point to the face that best matches how they feel. This scale is particularly useful for young children who may not have the verbal skills to describe their pain accurately using words or numbers.
B. Word-graphic
Explanation: The word-graphic pain scale typically uses a combination of words and drawings to assess pain, making it more suitable for children who are slightly older and can understand simple words and concepts.
C. Numeric
Explanation: The numeric pain scale involves asking the child to rate their pain on a scale from 0 to 10. This scale is more appropriate for older children who can understand and assign numerical values to their pain intensity.
D. CRIES
Explanation: The CRIES pain scale is often used for assessing pain in newborns and infants up to 6 months old. It focuses on crying, oxygen saturation, vital signs, and facial expressions.
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