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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Naloxone IV:
This choice is incorrect. Naloxone is an opioid receptor antagonist used to reverse the effects of opioid overdose. It works by displacing opioids from the receptors and rapidly reversing their effects. However, in this scenario, the client is experiencing pain 1 hour after receiving morphine, indicating that the morphine's analgesic effects have likely worn off. Naloxone is not used to manage pain, but rather to reverse opioid overdose.

B. Fentanyl transmucosal:
This choice is incorrect. Fentanyl transmucosal formulations are used for breakthrough pain in opioid-tolerant patients with chronic pain conditions. It is not typically the first choice for immediate pain relief after intravenous morphine administration. Additionally, it's worth noting that fentanyl transmucosal products, like fentanyl lollipops, are usually reserved for chronic pain management and may not be suitable for immediate post-administration pain relief.

C. Morphine tablet:
This is the correct choice. If the client is experiencing pain 1 hour after receiving morphine intravenously, it's reasonable to administer an oral or sublingual form of morphine for continued pain relief. Morphine tablets are commonly used for pain management and can provide sustained relief over a longer duration. This choice aligns with the patient's initial prescription for pain control.

D. Lidocaine patch:
This choice is incorrect. Lidocaine patches are used to manage localized neuropathic pain, such as postherpetic neuralgia. They work by numbing the skin and underlying tissues in the area where they are applied. While lidocaine patches can be effective for certain types of pain, they are not typically used to address the acute pain associated with cancer and immediate post-administration pain relief.

A. Administer 2 sprays of nicotine nasal spray in each nostril with each dose. B. Do not drink beverages while sucking on a nicotine lozenge. C. Chew nicotine gum for 10 min before spitting it out. D. Change the nicotine patch every other day.

Correct Answer is B

Explanation

A. Administer 2 sprays of nicotine nasal spray in each nostril with each dose: Nicotine nasal spray is administered as a single spray in each nostril with each dose.
B. Do not drink beverages while sucking on a nicotine lozenge.
This instruction is correct because when using nicotine lozenges, the client should not drink beverages while the lozeng is being dissolved in the mouth. The lozenge should be placed in the mouth and allowed to dissolve slowly over a period of about 20-30 minutes. Consuming beverages can wash away the nicotine from the lozenge too quickly, reducing its effectiveness.
C. Chew nicotine gum for 10 min before spitting it out: Nicotine gum should be chewed for a specific time period (about 30 minutes) until the nicotine is released, and then it should be parked between the cheek and gum until the taste fades, at which point it can be chewed again.
D. Change the nicotine patch every other day: Nicotine patches are usually changed daily, and the site of application should be rotated to avoid skin irritation.

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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?

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