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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

A. Retinal Hemorrhage B. Ventricular hypertrophy C. Cerebrovascular Disease D. Venous insufficiency E. Transient Ischemic Attacks (TIAs)

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

Explanation

A. Retinal Hemorrhage

Uncontrolled hypertension can damage the blood vessels in the eyes, leading to retinal hemorrhages. This can result in vision problems and, in severe cases, vision loss.

B. Ventricular Hypertrophy

Uncontrolled hypertension causes the heart to pump against increased resistance, leading to the thickening and enlargement of the left ventricle. Ventricular hypertrophy is a response to the increased workload on the heart and is associated with an increased risk of heart failure.

C. Cerebrovascular Disease

Hypertension is a major risk factor for cerebrovascular diseases, including strokes. Elevated blood pressure can damage the blood vessels in the brain, increasing the risk of stroke. Strokes can have serious consequences, affecting various neurological functions.

D. Venous Insufficiency

Venous insufficiency is not typically directly associated with uncontrolled hypertension. It is more commonly related to problems with the venous system, such as damaged valves in the veins, leading to poor blood flow back to the heart. While hypertension can affect arteries, venous insufficiency is a distinct condition.

E. Transient Ischemic Attacks (TIAs)

Uncontrolled hypertension increases the risk of transient ischemic attacks (TIAs), which are brief episodes of neurological dysfunction caused by temporary disruption of blood flow to the brain. TIAs are often considered warning signs of an increased risk of stroke.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a team of assigned clients. Which client is a priority for the nurse to check on first?

Correct Answer is D

Explanation

The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe. (SELECT ALL THAT APPLY)

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

Explanation

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally: 3 pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

The nurse should place a client being admitted to the hospital with suspected tuberculosis (TB) on what type of isolation?

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client’s needs?

A client with a complex cardiac history is scheduled for transesophageal echocardiography. Which of the following statements, if made by the nurse, is inappropriate?

A client with severe nausea has a one time order for ondansetron (Zofran) 8 mg IVPB to be administered over 15 minutes. The medication is diluted in 50 mL of D5W. The tubing drop factor is 15 gtt/mL. How many drops per minute should be given?

A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what antidote?

An older adult is newly diagnosed with primary hypertension, and has just been started on a beta-blocker. What information should the nurse include in the health education for this client?