A nurse is caring for a client with congestive heart failure who reports sudden weight gain, shortness of breath, and swelling in the ankles. What is the nurse's priority action?
Reassure the client that these symptoms are normal with CHF.
Encourage the client to increase fluid intake to prevent dehydration.
Notify the healthcare provider about the client's symptoms.
Administer a diuretic to reduce fluid retention.
The Correct Answer is C
A) This choice is incorrect because sudden weight gain, shortness of breath, and ankle swelling are not normal with CHF and may indicate worsening of the condition. The nurse should not reassure the client but rather take appropriate action to address the symptoms.
B) This choice is incorrect because the client's symptoms suggest fluid retention, and increasing fluid intake would exacerbate the condition. The nurse should not encourage the client to increase fluid intake without consulting the healthcare provider.
C) This choice is correct. The client's sudden weight gain, shortness of breath, and ankle swelling are signs of worsening congestive heart failure. The nurse's priority action is to notify the healthcare provider immediately to address the client's worsening condition and adjust the treatment plan as needed.
D) This choice is incorrect because administering a diuretic is not within the nurse's scope of practice without a healthcare provider's order. The nurse should first notify the healthcare provider to evaluate the client's condition and determine the appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because while electrolyte imbalances can have cardiovascular implications, they are not directly associated with diabetes mellitus or congestive heart failure.
B) This choice is incorrect because left-sided heart failure is not directly related to uncontrolled diabetes mellitus. However, diabetes can exacerbate heart failure if not well-controlled due to its impact on blood vessels and the heart.
C) This choice is incorrect because decreased afterload is not directly related to uncontrolled diabetes mellitus. Afterload refers to the resistance the heart has to overcome to eject blood into the circulation.
D) This choice is correct. Uncontrolled diabetes mellitus can lead to microvascular damage, particularly in the small blood vessels of the heart. This damage can contribute to heart muscle dysfunction and congestive heart failure. Diabetes is a significant risk factor for developing heart failure.
Questions
Correct Answer is A
Explanation
A) This choice is correct. Alcohol abuse can lead to dilated cardiomyopathy, a condition in which the heart becomes enlarged and weakened, contributing to congestive heart failure. Chronic alcohol consumption can cause toxic effects on the heart muscle, leading to impaired pumping function.
B) This choice is incorrect because malnutrition, while it can impact overall health, is not a direct precipitating cause of congestive heart failure. However, malnutrition can exacerbate heart failure symptoms and weaken the heart further.
C) This choice is incorrect because a sedentary lifestyle can be a risk factor for heart disease, including congestive heart failure, but it is not a direct precipitating cause of the client's condition in this scenario.
D) This choice is incorrect because occupational exposure to toxins can have health implications, but it is not directly related to the client's signs and symptoms of congestive heart failure in this case.
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