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
Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.
An explanation for incorrect choices:
B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.
C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.
D. Bradycardia is not typically associatedwith fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.
Correct Answer is C
Explanation
A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.
A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.
B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.
D: Diminished reflexes are not typically associated with a bladder infection.
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