A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

Encourage fluids.

Measure vital signs every 8 hr.

Obtain weight weekly.

Allow frequent rest periods.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Allow frequent rest periods.

Choice A rationale:

Encouraging fluids is not appropriate for a client with heart failure. Clients with heart failure often experience fluid overload due to the heart’s inability to pump effectively, leading to fluid retention. Encouraging additional fluid intake can exacerbate this condition, worsening symptoms such as edema and shortness of breath.

Choice B rationale:

Measuring vital signs every 8 hours may not be frequent enough for a client with heart failure, especially if they are experiencing acute symptoms. More frequent monitoring is often necessary to detect changes in the client’s condition promptly and to manage symptoms effectively.

Choice C rationale:

Obtaining weight weekly is not sufficient for a client with heart failure. Daily weight monitoring is crucial as it helps in detecting fluid retention early. Sudden weight gain can indicate worsening heart failure and the need for adjustments in treatment.

Choice D rationale:

Allowing frequent rest periods is essential for clients with heart failure. These clients often experience fatigue and decreased exercise tolerance due to reduced cardiac output. Frequent rest periods help in managing fatigue and preventing overexertion, which can worsen heart failure symptoms.

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Correct Answer is C

Explanation

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

A. Obtain blood pressure readings using the client's right arm. B. Limit range-of-motion exercises with the affected arm. C. Keep both arms below the level of the client's heart. D. Use the client's left arm to obtain blood samples.

Correct Answer is D

Explanation

The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.

A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.

B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.

C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.

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A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Correct Answer is D

Explanation

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