Nokea
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Select the six (6) statements that the nurse should include in the teaching plan for a client with heart failure.
Correct Answer: A,B,D,E,F,G
Rationale: Daily weighing monitors fluid status. Weight gain >2 lbs/day indicates fluid retention. C: Incorrect - Fluid restriction is typically 1.5-2 liters/day in heart failure. D: Correct - Potassium-rich foods support electrolyte balance with diuretics. E: Correct - NSAIDs can worsen heart failure. F: Correct - Rest and gradual activity prevent overexertion. G: Correct - Low sodium reduces fluid retention.