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

Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.

An explanation for incorrect choices:

A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.

C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.

D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.

A. Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F). B. Respiratory rate change from 12/min to 20/min. C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg. D. Heart rate change from 110/min to 68/min.

Correct Answer is C

Explanation

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

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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 assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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