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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A: The fifth intercostal space at the midclavicular line
The point of maximal impulse (PMI), also known as the apical impulse, is usually located in the fifth intercostal space at the midclavicular line. This is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.

Choice B: The first intercostal space at the sternal border
The first intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

Choice C: The second intercostal space at the sternal border
The second intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

A. A client who has a spinal cord injury and has a prescription for a condom catheter. B. A client who has immune thrombocytopenic purpura and a platelet count of 150,000/mm. C. A client who reports pain in his left calf and has a respiratory rate of 32/min. D. A client who requires a signed consent form prior to cardiac catheterization.

Correct Answer is C

Explanation

Choice A reason: While the client with a spinal cord injury does need care, it is not as immediately life-threatening as the symptoms described in choice C.

Choice B reason: A platelet count of 150,000/mm is within the normal range (150,000 to 450,000/mm), so this client's situation is not urgent.

Choice C reason: The client reporting pain in the left calf with an elevated respiratory rate could be experiencing a deep vein thrombosis (DVT) leading to a pulmonary embolism, which is a medical emergency.

Choice D reason: Obtaining a signed consent form is important but not as time sensitive as assessing and treating a potential DVT.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse?

Correct Answer is A

Explanation

A nurse is prioritizing care for four clients. Which of the following clients should the nurse see first?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory data of a client who is 1 day postoperative following an abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

A nurse is assisting with care for a client who received a tuberculin skin test 72 hours ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

A nurse is caring for a client who has dementia and is experiencing confusion. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about foot care for a client who has diabetes. Which of the following client statements indicates an understanding of the teaching?

A nurse is assisting with the plan of care for a client who has aspiration pneumonia and hypoxia. Which of the following actions should the nurse plan to take?

A nurse is reinforcing teaching with a client who is newly diagnosed with dumping syndrome. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

A nurse is providing care to a client who has sustained deep partial thickness burns to the back of both legs. Which of the following actions should the nurse anticipate taking?