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Which nursing action is a priority when caring for a client with heart failure?
- A. Encourage the client to drink fluids frequently
- B. Weigh the client daily to monitor fluid balance
- C. Increase fluid intake to prevent dehydration
- D. Limit the client's sodium intake
Correct Answer: B
Rationale: Weighing the client daily is a priority action when caring for a client with heart failure because it helps monitor fluid balance. This monitoring is essential in managing heart failure as it allows healthcare providers to assess for signs of fluid retention or depletion, which are crucial in adjusting treatment plans. Encouraging the client to drink fluids frequently (Choice A) may worsen fluid overload in heart failure patients. Increasing fluid intake (Choice C) can exacerbate fluid retention. While limiting sodium intake (Choice D) is important in heart failure management, monitoring fluid balance through daily weighing takes precedence as a priority nursing action.
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What are the signs and symptoms of fluid overload?
- A. Edema, shortness of breath, weight gain
- B. High blood pressure and jugular venous distention
- C. Low blood pressure and cyanosis
- D. Tachycardia and dizziness
Correct Answer: A
Rationale: The correct signs and symptoms of fluid overload include edema, shortness of breath, and weight gain. Edema is the abnormal accumulation of fluid causing swelling, shortness of breath can occur due to fluid accumulating in the lungs, and weight gain is often seen as a result of excess fluid retention. Choices B, C, and D are incorrect because high blood pressure and jugular venous distention are more indicative of conditions like heart failure, while low blood pressure and cyanosis are seen in conditions like shock or poor perfusion. Tachycardia and dizziness are not typical signs of fluid overload.
What is the nurse's responsibility when caring for a client with a chest tube?
- A. Check for air leaks in the tubing every 4 hours
- B. Clamp the chest tube for 30 minutes every 4 hours
- C. Encourage deep breathing and coughing every 2 hours
- D. Keep the client in a high Fowler's position
Correct Answer: A
Rationale: The correct answer is to check for air leaks in the tubing every 4 hours when caring for a client with a chest tube. This responsibility is crucial because it ensures proper chest tube function and helps prevent complications such as pneumothorax or hemothorax. Clamping the chest tube (Choice B) can lead to serious issues by causing a tension pneumothorax. Encouraging deep breathing and coughing (Choice C) is important for respiratory hygiene but is not directly related to chest tube care. Keeping the client in a high Fowler's position (Choice D) may be beneficial for some conditions but is not specific to chest tube management.
A nurse is caring for a client with a chest tube post-surgery. What is the most important assessment?
- A. Ensure the chest tube is clamped periodically
- B. Check for air leaks and ensure proper chest tube function
- C. Encourage deep breathing and coughing every 2 hours
- D. Ensure the client is positioned in a high Fowler's position
Correct Answer: B
Rationale: The correct answer is B: 'Check for air leaks and ensure proper chest tube function.' This is the most important assessment for a client with a chest tube post-surgery because it ensures that the chest tube is functioning properly. Checking for air leaks helps prevent complications such as pneumothorax or hemothorax. Choice A is incorrect because clamping the chest tube periodically can lead to serious complications and should not be done unless specifically ordered by a healthcare provider. Choice C is important for promoting lung expansion but is not the most critical assessment related to the chest tube. Choice D is also important for respiratory function but is not the priority when assessing a chest tube post-surgery.
A nurse is teaching a client with heart failure about dietary restrictions. What food should be limited?
- A. Bananas
- B. Leafy green vegetables
- C. Potatoes
- D. Whole grains
Correct Answer: A
Rationale: The correct answer is A: Bananas. Bananas are high in potassium, which should be limited in clients with heart failure to prevent electrolyte imbalances. While leafy green vegetables and whole grains are generally healthy options, they are not typically restricted in heart failure patients. Potatoes, although they contain potassium, are not as high in potassium as bananas and are not usually restricted as strictly.
What are the potential complications of a patient receiving hemodialysis?
- A. Infection and hypotension
- B. Pulmonary embolism and fluid overload
- C. Blood clot formation and electrolyte imbalance
- D. Low blood pressure and nausea
Correct Answer: A
Rationale: Corrected Question: What are the potential complications of a patient receiving hemodialysis?
Rationale: Infection and hypotension are common complications in patients undergoing hemodialysis. Pulmonary embolism and fluid overload (Choice B) are less common complications associated with hemodialysis. Blood clot formation and electrolyte imbalance (Choice C) are also potential complications but are not as common as infection and hypotension. Low blood pressure and nausea (Choice D) can occur but are not as prevalent as infection and hypotension.