A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Peripheral edema
Chest pain
Heart murmur
Crackles in lungs
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Planning to lower saturated fats to 10 percent of the daily calorie intake is a good dietary recommendation for a client who has hypertension, as it can help lower cholesterol, prevent atherosclerosis, and reduce the risk of cardiovascular complications.
a. "Limit your alcohol consumption to three drinks a day." is not correct, as it is too high for a client who has hypertension. The client should limit alcohol consumption to no more than one drink a day for women and two drinks a day for men, as alcohol can increase blood pressure and interfere with medication effectiveness.
c. "Diuretics are the first type of medication to control hypertension." is not accurate, as diuretics are not always the first choice of medication for hypertension. The choice of medication depends on the client's individual factors, such as age, race, comorbidities, and contraindications. Diuretics are one of the classes of antihypertensive drugs that can be used alone or in combination with other drugs.
d. "Reaching your goal blood pressure will occur within 2 months." is not realistic, as reaching the goal blood pressure may take longer than 2 months, depending on the client's baseline blood pressure, response to treatment, adherence to lifestyle modifications, and presence of other conditions. The client should monitor his blood pressure regularly and follow up with the provider as needed.
Correct Answer is D
Explanation
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
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