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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. "Apply the ointment to the skin every 4 hr.": Nitroglycerin topical ointment is applied every 6 to 8 hours, depending on the provider's instructions. Applying it every 4 hours may increase the risk of side effects such as hypotension or tolerance due to excessive dosing frequency.

B. "Spread the ointment in a thin, even layer.": The medication should be applied in a thin, consistent layer to allow for proper absorption through the skin. The dose is usually measured and spread using applicator paper, avoiding rubbing or massaging it in.

C. "Apply the ointment to the forearm.": The preferred application sites are hairless areas of the chest, back, or upper arms. The forearm is not typically used due to variability in absorption and the presence of thinner skin and more movement.

D. "Massage the ointment into the skin.": Nitroglycerin ointment should never be massaged into the skin. Massaging can lead to unpredictable absorption rates and an increased risk of hypotension or headache due to rapid systemic absorption.

A. Disconnecting the catheter from the drainage bag to empty the bag. B. Emptying the drainage bag when it is half full. C. Keeping the drainage bag above waist level. D. Using sterile gloves when emptying the drainage bag.

Correct Answer is B

Explanation

Rationale:

A. Disconnecting the catheter from the drainage bag to empty the bag: This increases the risk of introducing pathogens into the closed urinary drainage system, leading to potential catheter-associated urinary tract infections (CAUTIs). The drainage bag should be emptied without breaking the system.

B. Emptying the drainage bag when it is half full: This prevents backflow of urine, which could lead to infection or increased bladder pressure. Regular emptying also allows for accurate measurement of urine output and maintains client comfort.

C. Keeping the drainage bag above waist level: Elevating the bag above the bladder increases the risk of backflow of urine into the bladder, which can introduce bacteria and cause infection. The bag should always remain below the level of the bladder.

D. Using sterile gloves when emptying the drainage bag: Sterile gloves are not necessary for this procedure. Clean gloves are sufficient since the nurse or AP is not entering the sterile parts of the urinary system but rather emptying the bag from the outlet port.

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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?

Nursing Test Bank

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