A nurse is collecting data from a client who has left sided heart failure. For which of the following findings should the nurse notify the provider?
Weight loss of 1 kg (2.2 lb) in the past 24 hr
Pale, clammy skin
Fatigue when ambulating 152 m (500 ft)
Productive cough with pink, frothy sputum
The Correct Answer is D
A productive cough with pink, frothy sputum is indicative of pulmonary edema, which is a serious manifestation of left-sided heart failure.
It suggests fluid accumulation in the lungs, impairing gas exchange and oxygenation.
Prompt notification of the provider is crucial for appropriate intervention and management of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.
b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.
c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.
d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.
Correct Answer is C
Explanation
a.Adequate fluid intake is important while taking ciprofloxacin to prevent dehydration, especially if diarrhea occurs.
b. Ciprofloxacin can disrupt the normal balance of bacteria in the gastrointestinal tract, potentially leading to diarrhea. Informing the client about this possible side effect allows them to be prepared and take appropriate measures, such as maintaining hydration and notifying their healthcare provider if diarrhea becomes severe or persistent. However, warning about sunburnis crucial as it addresses a specific side effect (photosensitivity) that clients may not be aware of, and it provides actionable advice to mitigate the risk (use of sunscreen and protective clothing).
c.Ciprofloxacin, like other fluoroquinolone antibiotics, can increase sensitivity to sunlight (photosensitivity). Clients should be advised to use sunscreen, wear protective clothing, and avoid prolonged sun exposure while taking this medication.
d.Ciprofloxacin should not be taken with antacids, calcium supplements, or dairy products because they can interfere with the absorption of the medication. It's best to take ciprofloxacin either 2 hours before or 6 hours after taking antacids or products containing calcium, magnesium, aluminum, iron, or zinc.
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