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 Ib) 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.
Determine medication adherence by the client.
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
This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.
The provider should be informed of this change as soon as possible to prevent further complications.
Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.
While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.
Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.
While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.
Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.
While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Atorvastatin is a medication that belongs to a group of drugs called statins. It is used to lower blood levels of “bad” cholesterol (low-density lipoprotein, or LDL), to increase levels of “good” cholesterol (high-density lipoprotein, or HDL), and to lower triglycerides (a type of fat in the blood). The treatment has been effective if the LDL level is reduced, as high LDL levels can increase the risk of heart disease and stroke. A normal range for LDL is less than 100 mg/dL.
Choice A is wrong because urine specific gravity is a measure of how concentrated the urine is, not how much cholesterol is in the blood. A normal range for urine specific gravity is 1.005 to 1.0304.
Choice B is wrong because BUN (blood urea nitrogen) is a measure of how well the kidneys are working, not how much cholesterol is in the blood. A normal range for BUN is 7 to 20 mg/dL.
Choice D is wrong because blood glucose is a measure of how much sugar is in the blood, not how much cholesterol is in the blood.
A normal range for blood glucose is 70 to 100 mg/dL.
Correct Answer is D
Explanation
Metformin is a medication used to lower blood glucose levels in people with type 2 diabetes. Metoprolol is a beta-blocker used to treat high blood pressure and heart problems. If the nurse accidentally gives metformin instead of metoprolol, the client may experience hypoglycemia (low blood sugar), which can cause symptoms such as sweating, shakiness, confusion, and loss of consciousness. Therefore, the nurse should check the client’s glucose level and treat hypoglycemia if needed.
Choice A is wrong because HDL (high-density lipoprotein) is a type of cholesterol that is not affected by metformin or metoprolol.
Choice B is wrong because thyroid function levels are not affected by metformin or metoprolol.
Choice C is wrong because uric acid level is not affected by metformin or metoprolol.
Uric acid is a waste product that can cause gout if it accumulates in the joints. Normal ranges for blood glucose are 70 to 130 mg/dL before meals and less than 180 mg/dL two hours after meals.
Normal ranges for HDL are 40 to 60 mg/dL for men and 50 to 60 mg/dL for women.
Normal ranges for thyroid function levels vary depending on the specific test, but generally they are between 0.4 and 4.0 mIU/L for TSH (thyroid-stimulating hormone), 4.5 to 11.2 mcg/dL for T4 (thyroxine), and 80 to 180 ng/dL for T3 (triiodothyronine).
Normal ranges for uric acid are 3.4 to 7.0 mg/dL for men and 2.4 to 6.0 mg/dL for women.
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