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 D
Explanation
The correct answer is d
Choice A reason:
Administering filgrastim 12 hours after chemotherapy does not typically require an incident report. Filgrastim is often given at least 24 hours after chemotherapy to avoid the risk of increasing the toxicity of the chemotherapy agents. While the timing is closer than recommended, it does not necessarily constitute an error unless specific instructions for the timing were provided by the prescribing physician.
Choice B reason:
The medication vial sitting at room temperature for 2 hours before administration does not require an incident report. Filgrastim can be left out at room temperature for up to 24 hours before use. This is within the safe handling guidelines for the medication.
Choice C reason:
An absolute neutrophil count (ANC) of 2,500/mm³ is within the normal range, which is typically 1,500-8,000/mm³. Filgrastim is used to increase neutrophil counts in patients with low ANC due to chemotherapy. Since the ANC was not low before administration, this would not necessitate an incident report, although it may prompt a review of the necessity of the medication.
Choice D reason:
Flushing the client's IV line with dextrose 5% in water before and after the medication was administered is not the standard procedure and could potentially lead to medication errors or adverse effects. Filgrastim should be diluted in glucose 5% in water for intravenous infusion, but not used to flush the line. This deviation from the standard protocol is what necessitates an incident report.
Correct Answer is A
Explanation
The correct sequence for mixing regular insulin and NPH insulin in the same syringe is important to ensure proper dosing. The nurse should follow these steps:
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Inject air into the NPH (intermediate-acting) insulin vial: Injecting air into the NPH vial first helps to equalize the pressure in the vial, making it easier to withdraw the insulin later. This step is done first to avoid contaminating the regular insulin vial with NPH insulin.
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Inject air into the regular insulin vial: Next, inject an amount of air equal to the intended regular insulin dose into the regular insulin vial.This also helps to equalize the pressure and makes it easier to withdraw the insulin.
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Withdraw the regular insulin from the vial: The nurse should withdraw the regular insulin first because it is clear and not contaminated. This prevents any NPH insulin from mixing into the regular insulin vial.
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Withdraw the regular insulin from the vial: Finally, the nurse withdraws the NPH insulin. Since the regular insulin has already been drawn up, there is no risk of contaminating the regular insulin with NPH insulin.
This sequence ensures that you don't contaminate the vials, and you accurately withdraw the appropriate doses of each insulin type.
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