A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?
Administer diuretics.
Limit the client's fluid intake.
Insert an indwelling urinary catheter.
Place the client on a low-sodium diet.
The Correct Answer is A
Rationale:
A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.
B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.
C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.
D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Avoid talking to the client about the newborn: Avoidance may intensify the client’s sense of isolation and loss. Acknowledging the newborn and offering opportunities to express emotions helps validate the grief and supports emotional healing.
B. Offer to take pictures of the newborn for the client: Creating mementos such as photographs allows the client and family to honor the baby’s memory and supports healthy grieving. These keepsakes may become meaningful in the healing process over time.
C. Assure the client that she can have additional children: While well-intended, this statement can minimize the significance of the loss. Grief must be acknowledged in the present without shifting focus to future pregnancies, which may feel dismissive.
D. Discourage the client from allowing friends to see the newborn: Families should be supported in making choices about how they wish to say goodbye. Discouraging this may interfere with personal grieving preferences and disrupt closure.
Correct Answer is B
Explanation
Rationale:
A. The person holding financial power of attorney will make health care decisions based on the client's advance directives: A financial power of attorney manages financial matters, not health care decisions. A separate designation such as a health care proxy or medical power of attorney is needed for making medical decisions.
B. The client has the right to refuse medical treatment, even if health care providers recommend it: Under the Patient Self-Determination Act (PSDA), clients have the legal right to make autonomous decisions about their care, including the right to refuse or discontinue treatment, regardless of medical advice.
C. The client's eldest adult child has the right to change advance directives in an end-of-life situation: Advance directives reflect the client’s own decisions. No family member, regardless of birth order, has the legal authority to change them unless specifically authorized as a health care proxy and even then, only if the client is incapacitated.
D. If the client's advance directives are in writing and notarized, the client cannot change it in the future: Clients can revise or revoke advance directives at any time, as long as they remain mentally competent. Notarization does not make the document legally fixed or unchangeable.
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