A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Tachycardia

Weight gain

Decreased thirst

Thready pulse

Answer and Explanation

The Correct Answer is B

A.   While tachycardia can occur in some cases of heart failure as a compensatory mechanism, it's not a universal manifestation.
B.   In heart failure, weight gain is a common manifestation due to fluid retention caused by the heart's inability to pump blood effectively. This fluid buildup can lead to an increase in body weight, often evidenced by swelling in the legs, ankles, or abdomen.
C.   Heart failure often leads to increased thirst due to fluid overload and decreased cardiac output, resulting in poor tissue perfusion.
D.   A thready pulse may be present in heart failure due to decreased stroke volume, but it's not a primary manifestation typically associated with the condition.

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Correct Answer is D

Explanation

A: Changing the TPN bag and tubing every 24 hours is standard practice to prevent infection, so this action is appropriate.
B: Checking glucose levels every 6 hours is necessary because TPN can significantly affect blood glucose levels.
C: Gradually increasing the TPN rate is a standard procedure to monitor tolerance to the infusion.
D: This indicates a need for intervention. TPN lines should not be used for any other infusions to prevent contamination and interactions between the nutrition formula and medications.

A. Determine if the procedure is medically necessary for the client. B. Ensure that the client's family supports the provider's decision for surgery. C. Send the unsigned informed consent form to the facility's risk manager. D. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.

Correct Answer is D

Explanation

A. While determining if the procedure is medically necessary is important, the decision-making process should involve the client's designated surrogate, especially when the client is unable to make decisions.
B. While family support is valuable, the primary concern is ensuring that the client's designated surrogate, who is responsible for making healthcare decisions on behalf of the client, is informed and involved in the decision-making process.
C. Sending the unsigned informed consent form to the facility's risk manager does not address the immediate need to ensure that the client's healthcare surrogate is informed about the procedure and its implications.
D. When a client is unable to provide informed consent due to incapacitation, the nurse should communicate with the client's designated health care surrogate to ensure they are aware of the risks and benefits of the procedure and can make decisions on behalf of the client.

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A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Nursing Test Bank

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