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 B

Explanation

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

A. Monitor for at least 150 mL of drainage every hour. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Replace the unit when the drainage chamber is full.

Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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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

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