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, "I will attend a support group to help me handle difficulties when they occur." This statement indicates that the client is accepting the situation and taking proactive steps to manage any difficulties that may arise. Choice B is incorrect because relying on someone else to empty the bag suggests possible denial or avoidance of the situation. Choice C is incorrect because normal bowel movements after an ileostomy may not happen. Choice D is incorrect because it is not related to acceptance of the ileostomy. Choice B is not correct because it shows possible denial or avoidance of the situation. Choice C is not correct because normal bowel movements may not occur. Choice D is not correct because it is not related to acceptance of the ileostomy.
Correct Answer is A
Explanation
Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.
Reasons why the other options are not answers:
Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.
Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.
Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.
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