A nurse is caring for a client who has heart failure.
A nurse is caring for a client. After reviewing the findings above, which of the following actions should the nurse take? (For each potential provider's prescription, specify if the prescription is anticipated, nonessential, or contraindicated for the client)
Potential Prescriptions
Place the client on 24-hr urine collection.
Request to hold the client's metoprolol.
Place on sodium restriction of less than 1.500 mg per day.
Request for an increased dosage of furosemide.
Decrease the client’s oxygen to 1 L/min via nasal cannula.
Weigh the client daily.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"A"}}
Based on the information provided and the search results, here are the potential actions the nurse should take:
Choice A. nonessential
Reason: A 24-hour urine collection helps diagnose kidney problems. However, there is no clear indication from the provided information that the patient has kidney issues. Therefore, this prescription is at this point.
Choice B. nonessential
Reason: Metoprolol is a beta-blocker used in the treatment of heart failure. There is no clear indication from the provided information that the patient is experiencing adverse effects from metoprolol that would necessitate holding the medication.
Choice C. contraindicated
Reason: For people with heart failure, restricting dietary sodium intake to levels below the standard recommended maximum of about 2.3 grams per day does not bring additional benefits and may increase the risk of death.
Choice D. anticipated
Reason: Furosemide is a diuretic used in the treatment of heart failure. The patient's weight has increased, which could indicate fluid retention, a common symptom of worsening heart failure. Therefore, this prescription is .
Choice E. contraindicated
Reason: Oxygen therapy is used in heart failure patients to ensure adequate oxygen supply. However, the patient's oxygen saturation has decreased from 93% to 90%.
Choice F. anticipated
Reason: Daily weight monitoring is crucial in heart failure management as it can help detect fluid retention, a common symptom of worsening heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Providing three large meals daily may be overwhelming for a client experiencing changes in taste; smaller, more frequent meals may be better tolerated.
Choice B reason: Heating food before serving can enhance flavor, but it may not be sufficient to address the taste alterations caused by radiation therapy.
Choice C reason: Adding honey to sweeten fruit smoothies can improve taste but may not be suitable for all clients, especially those with diabetes or who need to limit sugar intake.
Choice D reason: Offering artificial saliva can help with dry mouth, a common side effect of radiation therapy, and may improve the client's ability to taste food.
Correct Answer is D
Explanation
Choice A reason: Calling the provider to discuss the partner's concerns may be part of comprehensive care, but it does not directly address the partner's immediate need for guidance on how to interact with the client.
Choice B reason: Encouraging the partner to wake the client to interact with family members is not appropriate. It is normal for a dying person to sleep more, and it is important to allow them to rest.
Choice C reason: Asking the provider to prescribe medication to minimize drowsiness is not appropriate in this context. Increased sleep is a common and natural part of the dying process, and it would not be beneficial to the client to be made more alert.
Choice D reason: Sitting quietly near the bedside provides comfort and support to both the client and the partner. It respects the natural process the client is going through and offers a peaceful presence.
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