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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.
Choice B rationale: Polypectomy is typically performed during the colonoscopy itself if polyps are detected. Most polyps are removed using snares or biopsy forceps during the same session, reducing the need for a second procedure. Scheduling another procedure is reserved for complex or large lesions requiring advanced techniques. Delaying removal increases the risk of progression to malignancy. Normal colonoscopy findings include pink mucosa and absence of polyps; any deviation warrants immediate intervention when feasible.
Choice C rationale: Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.
Choice D rationale: Enemas are not routinely recommended 2 days before colonoscopy. They may be used adjunctively on the day of the procedure for distal colon cleansing but are insufficient for full bowel preparation. Oral bowel prep agents like polyethylene glycol are preferred for complete evacuation. Enemas only reach the rectosigmoid region and do not cleanse the ascending or transverse colon. Incomplete prep compromises mucosal visualization and diagnostic yield, increasing false-negative rates.
Correct Answer is D
Explanation
The correct answer is: D.
Choice A reason: Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.
Choice B reason: Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.
Choice C reason: Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.
Choice D reason: Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.
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