While admitting an 82-year-old with acute decompensated heart failure to the hospital, the nurse learns that the client lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the client's discharge the nurse will facilitate a
transfer to a long-term care facility.
arrangements for around-the-clock care.
consult with a psychologist.
referral to a home health care agency.
The Correct Answer is D
A. Transfer to a long-term care facility is not necessary unless the client is unable to live independently despite support.
B. Around-the-clock care is excessive for a client who can still live alone and just needs assistance with medication management.
C. A psychologist is not the appropriate referral unless there are clear signs of mental health issues.
D. Referral to a home health care agency is appropriate to support the client at home, provide medication education, monitor adherence, and reduce the risk of readmission due to medication errors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Heart failure often presents with dyspnea, crackles (from pulmonary congestion), jugular vein distention, dependent edema, and hepatomegaly due to fluid overload and impaired cardiac output—these are classic signs.
B. Pulmonary embolism typically causes sudden dyspnea, chest pain, and tachypnea but not hepatomegaly or dependent edema.
C. Tension pneumothorax presents with tracheal deviation, absent breath sounds on one side, and hypotension—different from the systemic fluid overload signs described.
D. Cardiac tamponade presents with muffled heart sounds, hypotension, and jugular vein distention (Beck's triad), but it does not cause crackles, hepatomegaly, or peripheral edema.
Correct Answer is D
Explanation
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.
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