A nurse is admitting a client who has acute heart fallure. Which of the following prescriptions from the provider should the nurse anticipate?
Ambulate the client every 4 hr while awake.
Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr.
Provide the client with a 4 g sodium diet.
Administer enalapril 2.5 mg PO twice daily.
The Correct Answer is D
A. Although activity is encouraged, clients with acute heart failure may require rest to minimize cardiac demand.
B. Clients with acute heart failure typically need fluid restrictions, not boluses, which could exacerbate heart failure symptoms.
C. A low-sodium diet is usually recommended for heart failure clients to help manage fluid retention, not a high-sodium diet.
D. Enalapril is an ACE inhibitor often prescribed for clients with heart failure as it helps reduce blood pressure and decrease the workload on the heart.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Facilitating problem-solving skills is typically more relevant during the working phase of the therapeutic relationship, not the orientation phase.
B: During the orientation phase, establishing clear roles and responsibilities helps set expectations and boundaries for the therapeutic relationship.
C: Assisting the client in expressing alternative behaviors is also more relevant during the working phase when exploring and implementing change.
D: Determining previous coping skills is important but typically occurs during the assessment phase, which precedes the orientation phase of the therapeutic relationship.
Correct Answer is D
Explanation
A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.
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