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 ["C","E"]

Explanation

Based on the client's condition, the nurse should monitor the following:

C. Electrocardiogram (ECG) Rhythm: The client is experiencing chest pain with ST elevation, which indicates a possible myocardial infarction (MI). Continuous monitoring of the ECG rhythm is essential to identify any changes or dysrhythmias that may occur during the course of the client's care.

E. Vital signs: The client's tachycardia with ST elevation suggests cardiac involvement. Monitoring vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, is crucial to assess the client's hemodynamic status and detect any signs of deterioration or improvement.

The other options (A. WBC Count, B. Platelet Count, and D. Serum glucose level) are not directly related to the client's acute chest pain and the possible MI. While these tests may be ordered for other reasons or as part of the overall assessment, they are not the immediate priorities in this situation. Monitoring the ECG rhythm and vital signs are more relevant to the client's acute cardiac condition.

A. The client's peritoneal effluent appears cloudy. B. The client has an outflow volume of 1800 mL. C. The client has abdominal pain during the inflow phase. D. The client's abdomen appears bloated after the inflow.

Correct Answer is A

Explanation

Cloudy peritoneal effluent may indicate infection or peritonitis, which is a severe complication of peritoneal dialysis. Peritonitis can be life-threatening and requires immediate medical attention. The nurse should report this finding promptly to the health care provider for further evaluation and intervention.

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

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Naxlex Comprehensive Predictor Exams

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

Explanation

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?

Correct Answer is A

Explanation

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