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
Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that can cross-react with sulfa and should be avoided in clients with a sulfa allergy. Atorvastatin, prednisone, and digoxin do not contain sulfa and are safe for clients with a sulfa allergy.
Choice B: Atorvastatin does not contain sulfa and is safe for clients with a sulfa allergy.
Choice C: Prednisone does not contain sulfa and is safe for clients with a sulfa allergy.
Choice D: Digoxin does not contain sulfa and is safe for clients with a sulfa allergy.
Correct Answer is D
Explanation
The correct answer is: D.
Choice A reason: Asking a patient to rate their pain on a scale from 0 to 10 is a common method to assess the intensity of pain, not the quality. Zero indicates no pain, and ten represents the most severe pain imaginable. This scale is quantitative and helps in tracking the effectiveness of pain management over time.
Choice B reason: Inquiring if the pain is the same as it has been is a question that assesses the consistency or changes in the patient’s pain over time. It does not provide information about the quality of the pain but rather its course or any variations in the experience of pain.
Choice C reason: Asking whether the patient has any pain this morning is a question that determines the presence or absence of pain at a particular time. It does not elicit details about the nature or characteristics of the pain, which are essential to understanding its quality.
Choice D reason: Asking “What does your pain feel like?” is a qualitative question that aims to describe the characteristics of the pain, such as aching, stabbing, or burning. This information is crucial for diagnosing the cause of pain and tailoring appropriate treatment strategies. It directly addresses the quality of the pain, which is the focus of the nurse’s inquiry.
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