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 A

Explanation

Ringing in ears. Furosemide is a loop diuretic, which can cause ototoxicity as an adverse effect, resulting in ringing in the ears, hearing loss, or vertigo. The nurse should instruct the client to monitor for these adverse effects and report them immediately if they occur.

An explanation for incorrect choices:

B. Metallic taste is a common adverse effect of metronidazole or clarithromycin, but not furosemide.

C. Rhinitis is associated with intranasal or occasionally oral corticosteroid use.

D. Agitation is a side effect for stimulants, sedatives, or antidepressants.

A. The client has a history of breast cancer. B. The client takes ibuprofen for headaches. C. The client consumed citrus juice 3 days before the test. D. The client had a hemorrhoidectomy 1 year ago. E. The client had a hemorrhoidectomy 1 year ago.

Correct Answer is B

Explanation

The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.

Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.

Option C is incorrect because citrus juice does not affect the fecal occult blood test.

Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.

Reasons why the other options are not answered:

Option A: Breast cancer is not associated with false-positive fecal occult blood results.

Option C: Citrus juice does not affect the fecal occult blood test.

Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.

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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 reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?

Correct Answer is A

Explanation

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer is B

Explanation

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