A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
Provide the client with a 4g sodium diet.
Ambulate the client every 4 hr while awake.
Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr.
Administer enalapril 2.5 mg PO twice daily.
The Correct Answer is D
A) Provide the client with a 4g sodium diet: This is incorrect. Clients with acute heart failure typically require a low-sodium diet (often less than 2g per day) to help manage fluid retention and reduce workload on the heart.
B) Ambulate the client every 4 hr while awake: While mobility is important, the frequency and timing of ambulation in clients with acute heart failure should be carefully considered based on their stability and fatigue level. It may not be appropriate to ambulate every 4 hours.
C) Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr: This is generally not appropriate for clients with acute heart failure due to the risk of fluid overload. Instead, fluid management often involves restricting IV fluids and closely monitoring fluid balance.
D) Administer enalapril 2.5 mg PO twice daily: This prescription is appropriate. Enalapril, an ACE inhibitor, is commonly used to manage heart failure by reducing afterload and improving cardiac output. It helps alleviate symptoms and improve quality of life in heart failure patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A history of gastroesophageal reflux disease: This factor places the client at a higher risk for aspiration. Patients with gastroesophageal reflux disease (GERD) may experience backflow of stomach contents, which can lead to aspiration, especially when receiving enteral feedings.
B. A residual of 65 mL, 1 hr postprandial: While monitoring residual volumes is important to assess tolerance to feeding, a residual of 65 mL alone does not inherently indicate a high risk for aspiration. It may suggest that the feeding rate needs adjustment but isn't a direct risk factor.
C. Sitting in high-Fowler's position during the feeding: This position is actually protective against aspiration, as it promotes better gastric emptying and reduces the likelihood of reflux.
D. Receiving a high-osmolarity formula: While high-osmolarity formulas can sometimes lead to gastrointestinal discomfort or diarrhea, they do not directly increase the risk of aspiration. Proper management of feeding administration is key.
Correct Answer is B
Explanation
A) Flattening of the artificial airway cuff: This may indicate issues with the cuff pressure or an air leak but does not directly reflect the effectiveness of suctioning.
B) Decreased peak inspiratory pressure: This is the correct answer. A decrease in peak inspiratory pressure suggests that the airway is clearer, allowing for better airflow and indicating that the suctioning was effective in removing secretions that may have caused airway obstruction.
C) Presence of a productive cough: While this can indicate the expulsion of secretions, it may not be a reliable measure of the effectiveness of suctioning in a mechanically ventilated patient, as they may not be able to cough effectively.
D) Thinning of mucous secretions: While thinning secretions can be beneficial, it does not directly indicate that the suctioning itself was effective. The focus should be on airflow and pressure changes.
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