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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Splinter hemorrhages are a common sign of infective endocarditis but are not immediately life-threatening.
B. Fever is a typical manifestation of infection and expected in infective endocarditis, not a priority unless unresponsive to treatment.
C. Clusters of petechiae in the mouth indicate microemboli or vascular involvement, but they are not an acute threat.
D. Dyspnea is the priority finding because it may indicate heart failure or pulmonary embolism, both of which are serious complications of infective endocarditis and require immediate intervention.

A. Sick sinus syndrome B. Normal sinus rhythm C. Sinus bradycardia D. First degree heart block

Correct Answer is B

Explanation

A. Sick sinus syndrome – This involves an abnormal SA node function, often with varying rhythm disturbances (e.g., sinus pauses, bradycardia-tachycardia). The strip described is regular and does not reflect these changes.
B. Normal sinus rhythm – The rhythm is regular, the PR interval is within normal limits (0.12–0.20 seconds), the heart rate is 60 beats/min (within the normal range of 60–100), and P waves precede each QRS complex consistently.
C. Sinus bradycardia – Although the rate is 60, which is at the low end of normal, it is not below 60. Bradycardia is defined as <60 bpm.
D. First-degree heart block – First-degree AV block is characterized by a prolonged PR interval >0.20 seconds. The PR interval here is 0.16 seconds, which is normal.

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

When being discharged home, to assess fluid balance, a client with heart failure should be instructed to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?

Correct Answer is D

Explanation

A nurse is assessing an ECG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second. The overall heart rate is 60 beats/min. The nurse assesses the cardiac rhythm as:

Correct Answer is B

Explanation

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

A nurse assessing a client determines they are in the compensatory stage of shock. Which of the following findings support this conclusion?

The nurse is caring for a client who suddenly develops bradycardia. The client is breathing but with a decreased level of consciousness and decreased blood pressure. Which of the following treatments would be done by the nurse first?

What are the pathophysiologic changes that place a client who has suffered a myocardial infarction at risk for cardiogenic shock?

A nurse is caring for a client on a cardiac monitor and whose rhythm suddenly changes. There are no P waves; instead she observes wavy lines. The QRS complexes measure 0.08 second and are irregular. The client's heart rate is 120 beats/minute. The nurse interprets that this rhythm is:

A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

The nurse who is caring for a client in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is: