A nurse is assisting with the plan of care for a client who has heart failure. Which of the following interventions should the nurse recommend?

Offer snacks that are high in sodium.

Place the head of the client's bed flat.

Monitor the client's weight once per week.

Provide rest periods throughout the day.

Answer and Explanation

The Correct Answer is D

A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.

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Correct Answer is B

Explanation

A. Orthopnea: This is more commonly associated with left-sided heart failure, where fluid accumulation in the lungs causes difficulty breathing when lying flat.
B. Lower-extremity edema: This is correct as right-sided heart failure often leads to fluid retention in the body, resulting in swelling of the lower extremities.
C. Clammy skin: This is not a typical finding specific to right-sided heart failure and may be seen in other conditions or complications.
D. Pink, frothy sputum: This is characteristic of left-sided heart failure and pulmonary edema, not right-sided heart failure.

A. Wear a simple face mask when caring for the client. B. Wear a gown when caring for the client. C. Place the client in a negative air pressure room. D. Wear an N95 mask when in the client's room.

Correct Answer is D

Explanation

A. Wear a simple face mask when caring for the client: This is incorrect because pertussis is highly contagious and requires more stringent precautions, such as an N95 mask, to prevent transmission.
B. Wear a gown when caring for the client: This is incorrect as wearing a gown is not typically required for pertussis unless there is a risk of direct contact with respiratory secretions.
C. Place the client in a negative air pressure room: This is incorrect because pertussis does not require negative air pressure; it is transmitted through droplets, not airborne particles.
D. Wear an N95 mask when in the client's room: This is correct because an N95 mask provides the necessary protection against respiratory droplets that can transmit pertussis, ensuring proper protection for healthcare workers.

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A nurse is assisting with the plan of care for a client who has heart failure. Which of the following interventions should the nurse recommend?

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Naxlex Comprehensive Predictor Exams

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