a client is admitted with a diagnosis of congestive heart failure chf which intervention is most important to include in the plan of care
Logo

Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

2. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

3. The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.

4. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?

Correct answer: A

Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.

5. The nurse is monitoring a client who started taking a new medication for rheumatoid arthritis. What is the most important aspect to monitor?

Correct answer: D

Rationale: When a client starts a new medication for rheumatoid arthritis, it is crucial to monitor all necessary aspects based on the specific medication prescribed. Different medications can have varying side effects and impacts on different organ systems. Monitoring all relevant parameters ensures the early detection of any adverse effects and helps to maintain the client's safety. While monitoring for signs of gastrointestinal bleeding, liver function tests, and renal function tests are all important in certain situations, the priority is to conduct comprehensive monitoring based on the medication's known effects.

Similar Questions

The nurse is providing discharge instructions to a client with a diagnosis of peptic ulcer disease (PUD). Which dietary recommendation is most appropriate?
The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?
Which nursing activity is within the scope of practice for the practical nurse?
A client with chronic kidney disease is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
A nurse in a pediatric unit is preparing to administer medication to a child. What should the nurse do to ensure the correct dosage?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses