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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should instruct the client to avoid drinking beverages while sucking on a nicotine lozenge because this can interfere with the absorption of nicotine and reduce its effectiveness. Some possible explanations for the other choices are:

Choice B is wrong because chewing nicotine gum for 10 minutes before spitting it out is too short.

The recommended duration is at least 30 minutes to allow enough nicotine to be released and absorbed through the lining of the mouth.

Choice C is wrong because changing the nicotine patch every other day is not frequent enough.

The patch should be changed daily and applied to a different skin site to prevent irritation and ensure a steady dose of nicotine.

Choice D is wrong because administering 2 sprays of nicotine nasal spray in each nostril with each dose is too much.

The recommended dose is one spray per nostril, up to five times per hour or 40 times per day.

Using too much nasal spray can cause side effects such as nasal irritation, sneezing, coughing, headache, or nausea.

A. Calcium gluconate. B. Acetylcysteine. C. Flumazenil. D. Protamine sulfate.

Correct Answer is A

Explanation

Calcium gluconate is used to treat hypermagnesemia because it can help calm some symptoms such as impaired breathing, irregular heartbeat, and hypotension. Calcium also helps normalize the neuromuscular function that is affected by excess magnesium.

Choice B. Acetylcysteine is wrong because it is used to treat acetaminophen overdose and prevent kidney damage from contrast dye.

It has no role in treating hypermagnesemia.

Choice C. Flumazenil is wrong because it is used to reverse the effects of benzodiazepines, a class of sedative drugs.

It has no role in treating hypermagnesemia.

Choice D. Protamine sulfate is wrong because it is used to reverse the effects of heparin, an anticoagulant drug.

It has no role in treating hypermagnesemia.

Normal ranges for magnesium are 1.7 to 2.3 mg/dL or 0.7 to 1.1 mmol/L. Hypermagnesemia is defined as a magnesium level above 2.6 mg/dL or 1.5 mmol/L.

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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 Ib) since the last visit 2 days ago. Which of the following actions should the nurse take first?

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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 Ib) since the last visit 2 days ago.
Which of the following actions should the nurse take first?