The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

weigh the client to obtain a baseline for comparison

Insert an indwelling catheter

Draw blood for chemistry studies and a CBC

Administer furosemide 40mg PO

Answer and Explanation

The Correct Answer is A

A.   Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B.   Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C.   Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D.   Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

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Correct Answer is A

Explanation

A. This question assesses the client's level of orthopnea, which is a condition where the client experiences difficulty breathing when lying flat. People with heart failure may need to use multiple pillows to prop themselves up to breathe more easily at night, making it an important question to assess respiratory status.
B. Chest pain with exertion can be indicative of cardiovascular issues but this question does not directly assess the client's respiratory status.
C. Tight rings and shoes can indicate fluid retention and edema, but it does not provide specific information about respiratory status.
D. Frequent nighttime voiding (nocturia) is common in heart failure, but it relates more to kidney function and fluid retention rather than respiratory function.

A. Teach family members to assist with all ADLS once discharged B. Cluster activities to a time when the client has the most energy C. Provide alternating activity and rest periods D. Limit self-care activities until symptoms subside

Correct Answer is C

Explanation

A. While family support is important, encouraging complete assistance with all activities of daily living (ADLs) is not an ideal intervention. The goal is to maintain as much independence as possible, even if that means modifying or pacing activities. Encouraging complete dependency can lead to deconditioning and further loss of function.
B. Clustering activities is not the best intervention for this problem. Clustering involves grouping multiple tasks together at once, which can overwhelm the patient and lead to fatigue. Instead, the nurse should encourage pacing and spreading out activities to avoid overexertion, even if the patient has energy.
C. Providing alternating periods of activity and rest is a fundamental strategy in managing activity intolerance due to chronic heart failure. This approach helps balance the energy demands of daily activities with rest to prevent fatigue and overexertion. By alternating activity and rest, the patient can perform necessary tasks while minimizing strain on the heart.
D. The goal in chronic heart failure is to help the patient maintain independence and function as much as possible. Limiting self-care could lead to increased dependency and reduced quality of life. Activity modifications and appropriate pacing are better strategies.

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LAB	Result	Normal Range
Potassium	2.8 mEq/L	3.5-5.3mEq/L
Sodium	133 mEq/L	135-145 mEqL
Chloride	90 mEq/L	97-107 mEqL
Glucose	200 mg/dL	70mg/dL to 110mg/dL
Magnesium	2.5 mg/dL	1.6-2.2 mg/dL

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The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

Labs

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The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing the initial assessment of a client diagnosed with heart failure. Which question should the nurse ask to best assess the client's respiratory status?

Correct Answer is A

Explanation

The client problem of Activity Intolerance related to decrease in cardiac reserve is identified for a client with chronic heart failure. Which intervention should the nurse include in the plan of care related to this problem?

Correct Answer is C

Explanation

The nurse is caring for a client receiving a heparin infusion for disseminated intravascular coagulation (DIC). Which of the following lab results would indicate a sub-therapeutic level? An activated partial thromboplastin time (aPTT) of :……. (normal value: 25-35 seconds)

A client presents to the Emergency Department (ED) complaining of a "racing" heart and nervousness. The client also admits to a history of cocaine abuse. The cardiac monitor displays the rhythm below. Which nursing intervention should the nurse perform?

Labs

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