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 D
Explanation
Rationale:
A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.
B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.
C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.
D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.
Correct Answer is C
Explanation
Rationale:
A. Hematuria: Blood in the urine can occur with sickle cell disease due to renal papillary necrosis, but it is not specific to acute chest syndrome and does not require immediate emergency action in this context.
B. Sneezing: Sneezing is typically associated with upper respiratory infections or allergies and is not indicative of acute chest syndrome. It is not a critical symptom in this scenario.
C. Substernal retractions: Substernal retractions are a sign of respiratory distress and can indicate acute chest syndrome a life-threatening complication of sickle cell anemia. It involves pulmonary infiltration and can rapidly progress to hypoxia and respiratory failure, requiring urgent intervention.
D. Temperature 37.9° C (100.2° F): While fever in a sickle cell client should be closely monitored and reported, this temperature is low-grade. Alone, it does not immediately signal acute chest syndrome without accompanying respiratory symptoms.
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