Nokea
A nurse cares for a client with right-sided heart failure. The client asks, 'Why do I need to weigh myself every day?' How should the nurse respond?
- A. Daily weights will help us identify if you are gaining or losing fluid
- B. Daily weights will help us make sure that you're eating properly
- C. The hospital requires that all inpatients be weighed daily
- D. You need to lose weight to decrease the incidence of heart failure
Correct Answer: A
Rationale: Daily weights are critical for monitoring fluid retention or loss in clients with right-sided heart failure, as fluid accumulation is a key symptom of this condition. The other responses do not accurately address the purpose of daily weighing.
You may also like to solve these questions
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
- A. Assess the client's respiratory status
- B. Draw blood for sodium electrolytes
- C. Administer intravenous furosemide (Lasix)
- D. Ask the client about current medications
Correct Answer: A
Rationale: Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications in heart failure exacerbation. Monitoring electrolytes, administering diuretics, and asking about medications are important but do not take priority over assessing respiratory status.
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?
- A. A 36-year-old woman with aortic stenosis
- B. A 42-year-old man with pulmonary hypertension
- C. A 50-year-old woman who smokes cigarettes daily
- D. A 70-year-old man who had a cerebral vascular accident
Correct Answer: A
Rationale: Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. Causes of left ventricular failure include aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, 'I know a transplant is my last chance, but I don't want to become a vegetable.' How should the nurse respond?
- A. Would you like to speak with a priest or chaplain?
- B. I will arrange for a psychiatrist to speak with you
- C. Do you want to come off the transplant list?
- D. Would you like information about advance directives?
Correct Answer: D
Rationale: This client is verbalizing a real concern about negative outcomes of the surgery. Providing information about advance directives allows the client to express their wishes and feel some control over their future. The other responses do not directly address the client's concerns or empower them.
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
- A. Do you have trouble breathing or chest pain?
- B. Are you able to walk upstairs without fatigue?
- C. Do you awake with breathlessness during the night?
- D. Do you have new numbness in your legs?
Correct Answer: B
Rationale: Asking about the ability to walk upstairs without fatigue assesses functional capacity, which helps determine the extent of heart failure. The other questions address symptoms but do not directly evaluate the degree of limitation caused by heart failure.
The presence of an S3 gallop is noted in a client. What should the nurse do?
- A. Assess for symptoms of left-sided heart failure
- B. Document this as a normal finding
- C. Call the health care provider immediately
- D. Transfer the client to the intensive care unit
Correct Answer: A
Rationale: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.