A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, which of the following should the nurse anticipate using?
Anticoagulants
Antiembolism stockings
Oxygen
Diuretics
The Correct Answer is D
Choice A reason : Anticoagulants are medications that prevent blood clots. They are not typically used to manage fluid volume excess in left-sided heart failure. Instead, they may be used if the patient has an increased risk of clotting due to reduced mobility or atrial fibrillation, which can be associated with heart failure⁵.
Choice B reason : Antiembolism stockings are used to prevent deep vein thrombosis (DVT) and are not directly related to the management of fluid volume excess. They may be used in heart failure patients to prevent DVT due to reduced mobility but do not aid in fluid reduction⁵.
Choice C reason : Oxygen therapy can be used in left-sided heart failure to alleviate symptoms of dyspnea due to pulmonary congestion. However, it does not directly reduce fluid volume excess. It is a supportive treatment to ensure adequate oxygenation⁵.
Choice D reason : Diuretics are the primary treatment for reducing fluid volume excess in left-sided heart failure. They work by increasing urine output, which helps to reduce the volume of fluid in the body and alleviate symptoms such as pulmonary edema and peripheral edema⁵.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Implementing seizure precautions is necessary for a child with bacterial meningitis due to the increased risk of seizures associated with the condition.
Choice B reason : Placing the client in a semi-Fowler's position can help reduce intracranial pressure and facilitate breathing, which is beneficial for a child with meningitis.
Choice C reason : Admitting the client to a private room is important to prevent the spread of infection and provide a quiet environment to reduce the risk of seizures and other complications.
Choice D reason : Measuring head circumference every shift is not typically necessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants whose skull bones have not yet fused.
Correct Answer is C
Explanation
Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.
Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².
Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².
Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.
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