A nurse is caring for a client who has heart failure.

Exhibits

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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Padded tongue blades should not be used during a seizure as they can cause injury to the client.

Choice B reason: Wrist restraints are not routinely recommended for clients with seizure disorders and can cause injury if a seizure occurs.

Choice C reason: A backboard is not necessary at the bedside at all times for a client with a seizure disorder.

Choice D reason: Suction equipment should be readily available to clear the airway if secretions are present after a seizure.

A. Set the degree of flexion and extension as tolerated by the client. B. Align the client's joints with the joints on the frame. C. Pad the CPM device with a thick pillow. D. Place the client in high Fowler’s position.

Correct Answer is B

Explanation

Choice A reason: Setting the degree of flexion and extension is important, but it must be done after proper alignment to ensure the device is used effectively.

Choice B reason: Aligning the client's joints with the joints on the frame ensures that the CPM device moves the leg correctly and safely.

Choice C reason: Padding the CPM device with a thick pillow is not recommended as it can interfere with the device's movement and the client's positioning.

Choice D reason: Placing the client in high Fowler’s position is not related to the use of a CPM device and is not necessary for its operation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a seizure disorder. Which of the following supplies should the nurse have at the client's bedside at all times?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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