What is the best indication if the client with congestive heart failure is holding excess fluid?

Intake and output

Pitting pedal edema

Crackles in the bases of the lungs

Daily weights

Answer and Explanation

The Correct Answer is D

A. Intake and output:

Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.

B. Pitting pedal edema:

Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.

C. Crackles in the bases of the lungs:

Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.

D. Daily weights:

Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.

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Correct Answer is B

Explanation

A. Intermittent claudication:

Intermittent claudication is more commonly associated with peripheral arterial insufficiency rather than venous insufficiency. It is caused by inadequate blood flow to the muscles during activity, resulting in cramping or pain that typically resolves with rest.

B. Brownish discoloration to the legs:

Brownish discoloration to the legs, often referred to as hemosiderin staining, is a common finding in peripheral venous insufficiency. It occurs due to the breakdown of red blood cells and the deposition of hemosiderin in the tissues, especially around the ankles.

C. Weak or absent pedal pulses:

Weak or absent pedal pulses are more indicative of peripheral arterial insufficiency rather than venous insufficiency. Peripheral arterial disease can result in decreased blood flow to the extremities, leading to diminished pulses.

D. Unequal peripheral pulses between extremities:

Unequal peripheral pulses between extremities are also more suggestive of arterial insufficiency. Conditions such as atherosclerosis or arterial embolism can cause variations in pulses between different limbs.

A. withhold food and oral fluids before the procedure B. review medications the client has taken in the last 24 hours C. verify that written consent has been obtained D. check for iodine sensitivity E. administer all ordered oral medications

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

Explanation

Withhold food and oral fluids before the procedure

Withholding food and oral fluids before the procedure is essential to prevent complications during the cardiac catheterization. The client is typically NPO (nothing by mouth) for a specified period before the procedure.

B. Review medications the client has taken in the last 24 hours

Reviewing the client's medications is crucial to ensure that any medications affecting coagulation or blood vessels are appropriately managed before the cardiac catheterization.

C. Verify that written consent has been obtained

Verifying the presence of written consent is a critical step to confirm that the client has been adequately informed about the procedure, its risks, and benefits, and has given consent for the cardiac catheterization.

D. Check for iodine sensitivity

Checking for iodine sensitivity is important because iodinated contrast dye is commonly used during cardiac catheterization. Allergies or sensitivities to iodine contrast must be identified to prevent adverse reactions.

E. Administer all ordered oral medications

Administration of oral medications before the procedure depends on the specific medications and the healthcare provider's instructions. Some medications may be held, while others may be continued as prescribed.

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What is the best indication if the client with congestive heart failure is holding excess fluid?

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Naxlex Comprehensive Predictor Exams

Which of the following does the nurse recognize is common in peripheral venous insufficiency?

Correct Answer is B

Explanation

A client is scheduled for a cardiac catheterization. The nurse should do which of the following pre-procedure tasks? (SELECT ALL THAT APPLY)

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

Explanation

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What is the best indication if the client with congestive heart failure is holding excess fluid?

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which client data during assessment. (SELECT ALL THAT APPLY)