Nokea
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this patient to do to assess her fluid balance in the home setting?
- A. Monitor her blood pressure daily
- B. Assess her radial pulses daily
- C. Monitor her weight daily
- D. Monitor her bowel movements
Correct Answer: C
Rationale: To assess fluid balance at home, the patient should monitor daily weights at the same time every day. Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide information about fluid balance. Bowel function is not indicative of fluid balance.
You may also like to solve these questions
The nurse is caring for a 68-year-old patient the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should collect what assessment datum?
- A. Skin turgor
- B. Potassium level
- C. White blood cell count
- D. Peripheral pulses
Correct Answer: B
Rationale: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected in cases of digitalis toxicity.
A cardiac patients resistance to left ventricular filling has caused blood to back up into the patients circulatory system. What health problem is likely to result?
- A. Acute pulmonary edema
- B. Right-sided HF
- C. Right ventricular hypertrophy
- D. Left-sided HF
Correct Answer: A
Rationale: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the pulmonary circulation, right-sided HF, left-sided HF, and right ventricular hypertrophy do not directly occur.
The nurse is providing patient education prior to a patients discharge home after treatment for HF. The nurse gives the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?
- A. Know how to recognize and prevent orthostatic hypotension
- B. Weigh yourself weekly at a consistent time of day
- C. Measure everything you eat and drink until otherwise instructed
- D. Limit physical activity to only those tasks that are absolutely necessary
Correct Answer: A
Rationale: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily; detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the parameters of safety and comfort.
The nurses comprehensive assessment of a patient who has HF includes evaluation of the patients hepatojugular reflux. What action should the nurse perform during this assessment?
- A. Elevate the patients head to 90 degrees
- B. Press the right upper abdomen
- C. Press above the patients symphysis pubis
- D. Lay the patient flat in bed
Correct Answer: B
Rationale: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound would signal the possibility of impending HF?
- A. An S3 heart sound
- B. Pleural friction rub
- C. Faint breath sounds
- D. A heart murmur
Correct Answer: A
Rationale: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of HF.