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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Obtaining vital signs is important, but it is not the first action to take when a client is experiencing dyspnea.
Choice B reason: Administering heparin is a treatment for pulmonary embolism, but the immediate need is to address the client's breathing difficulty.
Choice C reason: Encouraging the client to cough and deep breathe may be helpful, but it is not the first action to take for acute dyspnea.
Choice D reason: Placing the client in high Fowler’s position can help improve breathing and oxygenation, which is the immediate priority for a client experiencing dyspnea.
Correct Answer is C
Explanation
Choice A reason: Placing the client in a private room with a private bathroom is a standard infection control practice but does not specifically address the management of the wound itself.
Choice B reason: Instructing visitors to perform hand hygiene is important, but the duration of 5 seconds is insufficient; the CDC recommends at least 20 seconds.
Choice C reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room helps prevent the spread of infection.
Choice D reason: Culturing the wound should be done before starting antibiotic therapy to ensure the correct antibiotic is chosen based on the culture results.
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