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
A potassium level of 3.2 mEq/L indicates hypokalemia, which can lead to muscle weakness. Difficulty swallowing, hyperreflexia, and diarrhoea are not typical signs of hypokalemia.
Other choices are not correct because:
B. Difficulty swallowing: Is not a typical sign of hypokalemia.
C. Hyperreflexia: Is not a typical sign of hypokalemia.
D. Diarrhea: Is not a typical sign of hypokalemia.
Correct Answer is ["A","D"]
Explanation
The correct answer is a. Dysuria and d. Hematuria.
Choice A rationale:
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
Choice B rationale:
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
Choice C rationale:
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
Choice D rationale:
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
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