A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?

“I’m urinating in larger amounts.”

“I have to sleep sitting up.”

“I suck on hard candy for my dry mouth.”

“I’ve lost 3 pounds in the last week.”

Answer and Explanation

The Correct Answer is B

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

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Correct Answer is B

Explanation

Moist heat can help reduce pain and stiffness in the joints by increasing blood flow and relaxing the muscles. Moist heat can be applied using warm compresses, heating pads, or warm baths.

Choice A is wrong because using a recliner when sitting for long periods can increase pressure on the knees and decrease circulation. A better option is to use a straight-backed chair with a footstool.

Choice C is wrong because sleeping on a soft mattress can cause poor alignment of the spine and joints, which can worsen pain and mobility. A firm mattress is recommended for clients with osteoarthritis.

Choice D is wrong because placing large pillows under the knees when lying in bed can limit the range of motion of the knees and cause contractures. A small pillow under the knees can provide some support and comfort, but it should not be too large or too high.

A. “Record your urination times for 24 hours before beginning the program.” B. “Drink 4 liters of fluid between 6:00 a.m. and 8:00 p.m.” C. “Void every 2 hours while awake.” D. “Eliminate caffeine from your diet.”

Correct Answer is A

Explanation

This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.

Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.

Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.

Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.

However, eliminating caffeine alone may not be enough to improve urinary incontinence.

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A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

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A nurse is caring for a client who has heart failure and is taking furosemide.
Which of the following statements by the client indicates a need for the nurse to intervene?