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.
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Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Asthma.
Choice A rationale:
Glaucoma is not a contraindication for propranolol. Beta-blockers like propranolol can actually be used to manage glaucoma by reducing intraocular pressure.
Choice B rationale:
Irritable bowel syndrome (IBS) is not a contraindication for propranolol. There is no direct interaction between propranolol and IBS that would prevent its use.
Choice C rationale:
Asthma is a contraindication for propranolol. Propranolol is a non-selective beta-blocker, which means it can block beta-2 receptors in the lungs, leading to bronchoconstriction and potentially severe asthma exacerbations.
Choice D rationale:
Migraine headaches are not a contraindication for propranolol. In fact, propranolol is often prescribed as a preventive treatment for migraines.
Correct Answer is D
Explanation
The nurse should recommend the pneumococcal vaccine to the client, as this is recommended for all adults over the age of 65 to prevent pneumococcal disease. Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States. Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it. Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.
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