When being discharged home, to assess fluid balance, a client with heart failure should be instructed to:
Monitor blood pressure.
Assess radial pulses.
Monitor bowel movements.
Monitor weight daily.
The Correct Answer is D
A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client showing signs of shock (e.g., cold, clammy skin, decreased bowel sounds, tachycardia) is not likely to stabilize and be released by the next day without intensive treatment.
B. The irreversible stage of shock is marked by profound hypotension, multi-organ failure, and unresponsiveness—more severe than this client’s current status.
C. The progressive stage of shock is characterized by impaired tissue perfusion, cold and clammy skin, tachycardia, hypoactive bowel sounds, and early signs of organ dysfunction. Even though the blood pressure is currently normal, perfusion is inadequate.
D. The compensatory stage is earlier and includes signs like tachycardia and restlessness, but perfusion to vital organs is still maintained, and skin may remain warm. This client’s cold skin and decreased bowel sounds suggest progression beyond this stage.
Correct Answer is B
Explanation
A. An atrial rhythm regular and ventricular rhythm irregular would suggest an arrhythmia such as atrial fibrillation or flutter with variable conduction—not sinus tachycardia.
B. In sinus tachycardia, the rhythm is regular, the P:QRS ratio is 1:1, meaning each P wave is followed by a QRS complex, and the origin is from the sinus node.
C. A 2:1 P:QRS ratio is characteristic of certain types of heart block or atrial flutter—not sinus tachycardia.
D. Irregular ventricular and atrial rhythms are seen in atrial fibrillation or other irregular arrhythmias, not sinus tachycardia.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.