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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In a client with chronic kidney disease (CKD), metabolic acidosis is a common acid-base disorder due to impaired excretion of acid and decreased bicarbonate reabsorption in the kidneys. The arterial blood gas values associated with metabolic acidosis in CKD are a low pH (acidemia), low bicarbonate (HCO3-), and normal or low partial pressure of carbon dioxide (PaCO2). Option A fits this pattern, with a pH of 7.25 (acidic), HCO3- of 19 mEq/L (low), and a PaCO2 of 30 mm Hg (within the normal to low range).
Option B shows a pH of 7.30 (acidic) but with a higher bicarbonate level of 26 mEq/L, which is not consistent with metabolic acidosis. The elevated bicarbonate level suggests metabolic alkalosis, which is not expected in a client with CKD.
Option C has a pH of 7.50 (alkaline) with an elevated bicarbonate level of 20 mEq/L and a low PaCO2 of 32 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.
Option D has a pH of 7.55 (alkaline) with an elevated bicarbonate level of 30 mEq/L and a low PaCO2 of 31 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.
Correct Answer is D
Explanation
ST-segment elevation on an electrocardiogram (ECG) is a critical finding and should be reported rapidly to the health care provider. It is a hallmark ECG change seen in myocardial infarction (heart attack). When there is myocardial ischemia or injury (such as in a heart attack), the ST segment
elevates above the baseline in the affected leads of the ECG. This elevation indicates that there is an ongoing loss of oxygen and blood supply to a part of the heart muscle.
ST-segment elevation is a medical emergency because it suggests acute coronary syndrome (ACS), which can rapidly progress to a myocardial infarction if not promptly treated. Immediate intervention is needed to restore blood flow to the affected coronary artery and prevent further damage to the heart muscle.
The other options listed (A) First-degree atrioventricular block, (B) Inverted P wave, and (C) Sinus tachycardia, while significant in some situations, do not have the same urgency as ST-segment elevation in the context of chest pain. They may require medical attention, but they do not typically indicate an acute myocardial infarction or an immediate life-threatening condition. ST-segment elevation is a critical finding that requires rapid intervention to preserve heart muscle function and prevent complications.
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