Nokea
A nurse prepares to discharge a client who has heart failure. Spice questions should the nurse ask to ensure the client's safety at home?
- A. Are your bedroom and bathroom on the first floor?
- B. What social support do you have at home?
- C. What is your typical daily diet?
- D. What spiritual beliefs may impact your recovery?
- E. Are you able to accurately weigh yourself at home?
Correct Answer: A,B,D
Rationale: To ensure safety, the nurse should assess structural barriers (e.g., bedroom/bathroom location), social support, and the ability to weigh daily for fluid monitoring. Diet and spiritual beliefs are relevant but not directly tied to safety.
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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 teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching?
- A. Hold the next dose of Imdur
- B. Increase your intake of foods that are high in potassium
- C. Hold this medication if your pulse rate is below 90 beats per minute
- D. Do not take this medication within 1 hour of taking an antacid
Correct Answer: D
Rationale: Digoxin should not be taken within 1 hour of antacids, as antacids can decrease its absorption. Holding Imdur is irrelevant to digoxin therapy. Potassium intake needs monitoring, but hypokalemia (not high potassium) is a concern with digoxin. The pulse rate threshold for holding digoxin is typically below 60 beats per minute, not 90.
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.
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.
After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate correct understanding of the teaching related to nutritional intake?
- A. I should limit my fluid intake to 2 liters per day
- B. I need to avoid adding salt to my foods
- C. I should eat foods high in potassium, like bananas
- D. I must avoid foods high in vitamin K
- E. I will check food labels for sodium content
Correct Answer: A,B,C,E
Rationale: Clients with CHF should limit fluid intake (typically to 2 liters/day), avoid adding salt, eat potassium-rich foods (especially if on diuretics), and check sodium content. Avoiding vitamin K is specific to clients on warfarin, not a general CHF requirement.