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

Exhibits

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Fluid volume deficit

The client is receiving Furosemide (a diuretic) at a significant dose (80 mg IV three times per day). This medication promotes diuresis to reduce fluid overload in heart failure. The client's weight decreased from 97.5 kg on admission to 90.7 kg on Day 2, indicating a fluid loss of approximately 6.8 kg (about 15 pounds). This substantial weight loss suggests a risk for fluid volume deficit, which can lead to hypovolemia and potential complications such as hypotension and decreased tissue perfusion.

Acute kidney injury (AKI)

The client's BUN level increased from 10 mg/dL on admission to 20 mg/dL on Day 2, which suggests impaired kidney function. This change may indicate a decrease in glomerular filtration rate due to decreased renal perfusion secondary to fluid loss from diuresis. AKI is a known complication in heart failure patients receiving diuretic therapy, especially if there is inadequate monitoring and adjustment of diuretic doses.

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Correct Answer is D

Explanation

A Breathing exercises can help improve lung function and oxygenation. However, the specific type of breathing exercise is crucial. Emphysema typically involves air trapping due to loss of elasticity in the lungs, so teaching a breathing exercise with a longer exhalation phase (to facilitate complete exhalation and prevent air trapping) would be more beneficial than emphasizing a longer inhalation phase.

B. Fluid restriction is not typically indicated for clients with emphysema. It is more relevant for conditions where fluid overload can exacerbate symptoms (like congestive heart failure). In emphysema, maintaining adequate hydration is important to keep secretions thin and more manageable for clearing.

C.Incentive spirometry is used to help promote deep breathing and prevent atelectasis (lung collapse) by encouraging the client to take slow, deep breaths. However, incentive spirometry is typically more useful for clients recovering from surgery or immobilized clients rather than for those with emphysema.

D. The use of oxygen therapy at 2 L/min is a standard intervention for clients with emphysema who have low oxygen levels, as it helps maintain proper oxygenation. It is crucial to manage oxygen levels carefully to prevent complications such as hypoxia or pulmonary hypertension while avoiding excessive oxygen, which may reduce the patient's drive to breathe.

A. Wear a surgical mask when providing care to the client. B. Perform a Mantoux skin test on the client. C. Assign the client to a negative pressure airflow room. D. Recommend that the client's family members receive antiviral therapy.

Correct Answer is A

Explanation

A Pertussis is highly contagious and spread through respiratory droplets. Wearing a surgical mask when providing care to the client helps prevent the spread of the bacteria to others in the healthcare setting. This is a standard precaution to minimize transmission of respiratory infections.

B. A Mantoux test, or tuberculin skin test, is used to detect tuberculosis (TB) infection, not pertussis. It is not relevant to the diagnosis or management of pertussis. The focus should be on clinical assessment and appropriate treatment for pertussis.

C Pertussis does not typically require isolation in a negative pressure airflow room. Standard precautions, including wearing a surgical mask, are generally sufficient to prevent transmission. Negative pressure rooms are typically reserved for airborne infections like tuberculosis or measles.

D. Pertussis is caused by a bacterial infection (Bordetella pertussis), not a virus. Antiviral therapy is not effective against bacterial infections such as pertussis. Family members and close contacts of the client should receive prophylactic antibiotics to prevent spread of the infection, not antiviral therapy.

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A nurse is caring for a client who has heart failure. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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

Exhibits

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing
dropdown
and
dropdown