Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

"I will use the nitroglycerin patch whenever I have chest pain."

"I will take furosemide (Lasix) every day just before bedtime."

"I will call the clinic if my weight goes up 3 pounds in a week."

"I will use an additional pillow if I am short of breath at night.”

Answer and Explanation

The Correct Answer is C

The statement "I will call the clinic if my weight goes up 3 pounds in a week" indicates that the teaching about heart failure was effective. Monitoring weight is an essential self-care measure for patients with heart failure to manage fluid retention effectively. A sudden weight gain of 2-3 pounds in a week can indicate fluid retention and worsening heart failure. It is crucial for the patient to report such weight changes promptly to the healthcare provider or clinic to adjust medication doses or treatment plans as needed.

The other statements are incorrect:

A) "I will use the nitroglycerin patch whenever I have chest pain." Nitroglycerin is not typically used to manage heart failure. It is used for angina, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed coronary arteries.

B) "I will take furosemide (Lasix) every day just before bedtime." While furosemide is a diuretic commonly prescribed for heart failure to reduce fluid retention, it is not usually taken just before bedtime. Taking furosemide in the evening may lead to frequent nighttime urination and disrupt sleep.

D) "I will use an additional pillow if I am short of breath at night." Using an extra pillow may provide temporary relief for positional dyspnea (shortness of breath when lying flat) but is not an appropriate long-term strategy for managing heart failure. Elevated pillows may not effectively improve breathing and can lead to neck strain. Instead, patients with heart failure should be encouraged to sleep with their head slightly elevated on a regular basis, using a wedge pillow or adjustable bed if needed. Managing fluid retention and adhering to prescribed medications are essential for improving heart failure symptoms and preventing complications.

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Correct Answer is A

Explanation

A 3 lb weight gain in a short period, especially overnight, is indicative of fluid overload in a client with end-stage kidney disease receiving hemodialysis. Hemodialysis is performed to remove excess fluid and waste products from the body. If the client is experiencing fluid overload, it means that their body is retaining more fluid than it should, and this can lead to complications such as pulmonary edema, heart failure, and other cardiovascular problems. The nurse should identify this finding as an indication of potential fluid overload and report it to the healthcare provider for further evaluation and intervention.

A. Lung sounds B. Facial swelling C. Level of anxiety D. Intake and output

Correct Answer is A

Explanation

In a patient with acute decompensated heart failure (ADHF), the priority nursing assessment is to auscultate lung sounds. ADHF is characterized by the sudden worsening of heart failure symptoms, which may include pulmonary congestion and fluid accumulation in the lungs. Assessing lung sounds helps to identify signs of pulmonary edema, which is a serious complication of ADHF.

The nurse should listen for crackles or rales, which are abnormal lung sounds caused by the presence of fluid in the alveoli. These findings suggest that the patient is experiencing fluid overload and inadequate gas exchange in the lungs. Prompt recognition of pulmonary edema allows for early intervention, such as administering diuretics or other medications, to relieve fluid overload and improve respiratory function.

While the other options (B) Facial swelling, (C) Level of anxiety, and (D) Intake and output, are important assessments in a patient with heart failure, they are not the priority in a patient with manifestations of acute decompensated heart failure. The priority is to assess for signs of respiratory

distress and pulmonary congestion, as these can quickly lead to respiratory failure and life threatening complications.

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Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload?

Correct Answer is A

Explanation

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Correct Answer is A

Explanation

Which statement by a client with newly diagnosed heart failure indicates to the nurse that teaching was effective?

The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

After the nurse gives IV atropine to a patient with symptomatic type 1. second-degree atrioventricular (AV) block, which finding indicates that the drug has been effective?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Which information is most important for the nurse to include when teaching a client newly diagnosed with hypertension?

During the 48 hours after a myocardial infarction (MI), a nurse should assign the highest priority to monitoring the patient for what complication?

A female client with chronic kidney disease (CKD) is receiving peritoneal dialysis with 2-L inflows. Which information should the nurse report promptly to the health care provider?

The nurse recalls that which type of drug therapy is used to treat volume overload in patients with acute decompensated heart failure (ADHF)?