A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

Use non-steroidal anti-inflammatory drugs for discomfort.

Limit sodium in the diet to 3.5 g/day.

Place client in a lateral position.

Limit fluid intake to 2 liters/day.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Using non-steroidal anti-inflammatory drugs (NSAIDs) for discomfort is not recommended for patients with heart failure because NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also interfere with the effects of certain heart failure medications.

Choice B reason:

Limiting sodium in the diet to 3.5 g/day is not restrictive enough for heart failure patients. Typically, heart failure management involves reducing sodium intake to around 2-2.3 g/day to help prevent fluid retention and reduce the workload on the heart.

Choice C reason:

Placing the client in a lateral position is not specifically beneficial in the management of heart failure. While changing positions can be part of general patient care, it does not directly address the fluid balance or cardiac workload in heart failure patients.

Choice D reason:

Limiting fluid intake to 2 liters/day is a common intervention for managing heart failure. This helps to prevent fluid overload, which can exacerbate heart failure symptoms and lead to complications such as pulmonary edema. Maintaining a careful balance of fluid intake is essential for managing heart failure effectively.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Increased oxygen saturation. B. Urine output less than 30 mL/hr. C. Decreased level of consciousness. D. Heart rate of 34 beats/min.

Correct Answer is ["B","D"]

Explanation

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

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A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Correct Answer is ["B","D"]

Explanation

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