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 B
Explanation
This is because hydromorphone is a controlled substance and any unused portion should be discarded in the presence of a witness. Some possible explanations for the other choices are:
Choice A is wrong because storing the remaining half of the pill in the automated medication dispensing system could lead to errors in dosage or diversion of the drug.
Choice C is wrong because returning the remaining medication to the facility’s pharmacy is not a recommended practice for controlled substances and could also result in errors or diversion.
Choice D is wrong because placing the remaining half of the pill in the unit-dose package could compromise the integrity and stability of the medication and expose it to environmental factors.
Normal ranges for hydromorphone are not applicable as it is a synthetic opioid analgesic that does not have a therapeutic level.
However, some factors that may affect its pharmacokinetics and pharmacodynamics are age, weight, renal function, liver function, genetic polymorphisms, and drug interactions.
Correct Answer is B
Explanation
Hot flashes are a common side effect of tamoxifen, which is hormone therapy for breast cancer that blocks the action of estrogen.
Tamoxifen can cause menopause-like symptoms in women, such as irregular or missing periods, vaginal discharge or bleeding, and mood changes. Choice A is wrong because tinnitus (ringing in the ears) is not a known side effect of tamoxifen.
Choice C is wrong because urinary frequency (needing to urinate more often) is not a known side effect of tamoxifen.
Choice D is wrong because constipation (difficulty passing stools) is not a known side effect of tamoxifen.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today