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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Vomiting: While nausea and vomiting can occur during pregnancy, they are not specific complications related to amniocentesis. The nurse should focus on more serious potential complications following the procedure.
B) Contractions: This is the most relevant complication to monitor for after an amniocentesis. The procedure can stimulate uterine contractions, which may lead to preterm labor, especially at 33 weeks of gestation. Monitoring for contractions is essential to ensure the safety of both the mother and the fetus.
C) Hypertension: Hypertension is not a direct complication associated with amniocentesis. While the stress of the procedure may affect blood pressure, it is not a typical monitoring concern immediately following the procedure.
D) Epigastric pain: Although epigastric pain can occur in pregnancy, it is not a specific complication of amniocentesis. Monitoring should focus on uterine activity and signs of labor rather than general abdominal pain unless it is severe or accompanied by other concerning symptoms.
Correct Answer is A
Explanation
A) Determine if the client has thoughts about self-harm: In situations of acute grief and trauma, assessing for suicidal ideation is the priority. The nurse must ensure the client's safety first, as the loss of a partner in such a tragic circumstance can lead to overwhelming feelings of despair and hopelessness.
B) Review the client's available social support system: While understanding the client’s social support is important for ongoing care and coping strategies, it is not the immediate priority. Ensuring the client’s safety takes precedence over evaluating their support network.
C) Empower the client to feel that he is in charge of his life: Empowering the client is a valuable goal for long-term recovery, but it should come after assessing immediate safety and mental health needs. The client may not be in a state to feel empowered until basic concerns about their well-being are addressed.
D) Find the client a temporary shelter where he can feel safe: While finding shelter is crucial for the client’s physical safety and security, this action should follow the immediate assessment of the client’s mental health and any risk of self-harm. Ensuring psychological safety is the first step before addressing logistical needs.
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