The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Consume 2500mL of fluids per day during the summer months

Maintain daily sodium intake of no more than 2gm per day

Notify the health care provider if weight increases by 5 Ibs. in one week

If shortness of breath occurs with minimal activity, notify the provider

Take furosemide anytime when feeling bloated or short of breath

Answer and Explanation

Correct Answer : B,C,D

A.   Fluid intake may need to be regulated in heart failure patients, consuming 2500mL of fluids per day may be too high for some patients, depending on their condition and whether they are on fluid restriction. Fluid management should be individualized, and the provider should specify the amount based on the patient's condition.
B.   A low-sodium diet is essential for heart failure patients to help reduce fluid retention, decrease blood pressure, and lessen the burden on the heart. The American Heart Association recommends a sodium intake of no more than 2,000-2,300 mg per day for heart failure patients.
C.   Rapid weight gain is a sign of fluid retention, which can indicate worsening heart failure. A gain of 2-3 pounds in a single day or 5 pounds in a week should prompt the client to contact their healthcare provider for further evaluation.
D.   Shortness of breath with minimal activity can be a sign of worsening heart failure or fluid overload. This symptom should be reported immediately to a healthcare provider for further evaluation and possible adjustments to treatment.
E.   Furosemide (a diuretic) is often prescribed to reduce fluid retention but it should not be taken without proper guidance or as a response to symptoms without consulting the healthcare provider. Taking diuretics at the wrong time or in excessive amounts can lead to dehydration and electrolyte imbalances, which could worsen the condition.

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Correct Answer is B

Explanation

A. The pacemaker wire for a DDD device is placed in the right atrium and right ventricle, not the left ventricle.
B. This is the correct description of a DDD pacemaker, which has wires in both the right atrium and right ventricle to monitor and pace both chambers when needed.
C. This is incorrect because a DDD pacemaker does not pace both ventricles.
D. This is inaccurate because a DDD pacemaker does not fire with every heartbeat; it only fires when the heart’s natural electrical activity is insufficient.

A. Report the findings and anticipate a medical prescription for amiodarone B. Initiate a rapid response call and increase the monitor's sensitivity C. Start compressions and prepare for defibrillation D. Establish unresponsiveness and check the carotid pulse

Correct Answer is D

Explanation

A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

The nurse is providing discharge instructions for the client diagnosed with heart failure. Which information should the nurse provide to assist the client to limit complications and prevent future hospitalizations? (SELECT ALL THAT APPLY).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions to a client who has had a permanent pacemaker inserted. The information in the chart indicates that the device is a DDD. What will the nurse explain about this pacemaker?

Correct Answer is B

Explanation

The nurse observes the following rhythm of a client on the telemetry unit. Which action should be completed first?

Correct Answer is D

Explanation

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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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