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 B
Explanation
The patient is apneic (not breathing) and has no palpable pulses, indicating a cardiac arrest or severe cardiovascular compromise. In this situation, the most appropriate action for the nurse to take next is to start cardiopulmonary resuscitation (CPR) immediately.
CPR is a life-saving procedure that combines chest compressions and rescue breaths to circulate oxygenated blood to vital organs when the heart is not effectively pumping. In the case of cardiac arrest, early initiation of CPR is critical to improve the chances of survival and minimize potential brain damage.
The heart monitor shows sinus tachycardia, rate 132, which suggests that the electrical impulses are reaching the heart, but the heart is not effectively pumping blood due to the lack of a palpable pulse. This condition requires immediate intervention with CPR rather than other treatments such as synchronized cardioversion (option A) or administering atropine (option D).
While applying supplemental oxygen via a non-rebreather mask (option C) is generally important in many emergency situations, it is not the immediate priority when a patient is apneic and has no palpable pulses. In such cases, CPR takes precedence to restore circulation and maintain oxygen delivery to the body's vital organs.
Correct Answer is C
Explanation
For a patient admitted with syncopal (fainting) episodes of unknown origin, the most appropriate action to include in the plan of care is to instruct the patient to call for assistance before getting out of bed.
Syncope can be caused by various factors, including orthostatic hypotension (a drop in blood pressure upon standing) or cardiac-related issues. One of the common triggers for syncopal episodes is getting up from a lying or sitting position too quickly. By instructing the patient to call for assistance before getting out of bed, the nurse aims to prevent falls and potential injuries that may occur due to sudden fainting episodes.
While it's essential to educate the patient about potential causes of syncope (option A) and the benefits of implantable cardioverter-defibrillators (option B) if applicable to their condition, these actions may not directly address the immediate safety concern of preventing falls during syncopal episodes.
Option D, teaching the patient about the need to avoid caffeine and other stimulants, may be relevant if stimulants are identified as potential triggers for syncope in this particular patient. However, it is not the most critical action to include in the initial plan of care for a patient with syncopal episodes of unknown origin.
In summary, the top priority for the nurse is to ensure the safety of the patient by instructing them to call for assistance before getting out of bed to prevent falls during syncopal episodes until further evaluation and diagnosis can determine the cause of the fainting episodes.
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