question one a 65-year-old patient with a history of heart failure presents with increased shortness of breath a weight gain of 3 kilg in one week and swollen ankles which action should the nurse take first a instruct the patient to restrict fluid intake B administer prescribed diuretic medication C encourage the patient to rest in a high Fowler's position D assess lung sounds and check for other signs of fluid overload correct answer D assess lung sounds and check for other signs of fluid overload rationale initial assessment is crucial in heart failure patients presenting with these symptoms assessing lung sounds and checking for other signs of fluid overload helps to determine the severity of the condition and guides immediate intervention administering diuretics fluid restriction and positioning are subsequent actions based on the initial assessment question two which statement by a patient with heart failure taking an alil an Ace inhibitor indicates a need for further education a I will report any signs of swelling or rapid weight gain B B I should avoid salt substitutes that contain potassium C I will take this medication even if I am feeling well D if I develop a dry cough I will stop taking the medication immediately correct answer D if I develop a dry cough I will stop taking the medication immediately rationale a dry cough is a common side effect of AC inhibitors but patients should not stop the medication without consulting a health care provider it's essential to educate patients about managing side effects and the importance of not discontinuing medications without guidance question three the nurse is caring for a patient with heart failure which of the following laboratory results should the nurse report immediately a sodium 140 mil equivalent per liter B potassium 3.0 mil equivalent per liter C hemoglobin 12 G per deciliter D blood uan nitrogen bu 18 mg per deciliter correct answer B pottassium 3.0 mil equivalent per liter rationale a potassium level of 3.0 mil equivalent per liter is considered low hypokalemia and can be particularly dangerous and heart failure patients especially those on diuretics it can lead to cardiac dysmas the other values are within normal ranges question four the nurse is teaching a patient with heart failure about energy conservation techniques which statement by the patient indicates a need for further teaching a I will perform activities slowly and rest as needed B it's best to do all my activities in the morning when I have more energy C I can sit on a chair while showering or cooking D I will ask family members for help with daily tasks correct answer B it's best to do all my activities in the morning when I have more energy rationale patients with heart failure should be taught to Pace themselves and spread activities throughout the day to avoid excessive fatigue doing all activities in the morning can lead to exhaustion and worsen heart failure symptoms question five a patient with heart failure is prescribed furosemide a loop diuretic which statement by the patient indicates effective teaching a I will take the medication at bedtime B I should report muscle weakness or cramps C I will limit my fluid intake to 500 ml per day D weight gain is a common side effect of this medication answer B I should report muscle weakness or cramps rationale muscle weakness or cramps can be a sign of electrolyte imbalances particularly hypokalemia which can occur with Loop diuretic therapy patients must be aware of these symptoms and report them immediately taking the medication at bedtime could disrupt sleep due to the need for frequent urination and limiting fluid to 500 milliliters per day is too restrictive for most heart failure patients unless specifically instructed weight gain is not a typical side effect of furosemide it usually causes weight loss due to diuresis question six a nurse is assessing a patient with heart failure which finding should the nurse prioritize for immediate intervention a blood pressure of 13 over 85 mm of mercury B weight gain of one pound in the past 24 hours C S3 heart sound on oscilation D oxygen saturation of 88% on room air correct answer D oxygen saturation of 88% on room air rationale an oxygen saturation of 88% indicates Ates hypoxemia and requires immediate intervention to improve oxygenation the other findings while important in heart failure management do not require immediate intervention like hypoxemia does question seven a patient with heart failure is prescribed dioxin which of the following should the nurse instruct the patient to Monitor and report a increased urination B vision changes such as yellow Halos C sudden weight loss D increased appetite correct answer B vision changes such as seeing yellow Halos rationel vision changes particularly seeing yellow Halos around lights are a sign of dioxin toxicity it is crucial for patients to be aware of this and report it immediately the other options are not typically associated with dixin therapy question 8 the nurse is planning care for a patient with heart failure which intervention should be included to prevent pulmonary complications a encourage the patient to lie flat for long periods B administer oxygen therapy as prescribed C limit fluid intake to 1 liter per day D avoid the use of diuretics correct answer B administer oxygen therapy as prescribed rationale oxygen therapy can help to prevent pulmonary complications in heart failure patients by improving oxygenation lying flat can exacerbate pulmonary congestion limiting fluid intake should be individualized and diuretics are often used in heart failure management question nine a patient with heart failure reports increasing fatigue and shortness of breath the nurse notes bilateral pitting edema in the lower extremities which nursing action is most appropriate a encourage increased physical activity B apply tight compression stockings C Elevate the patient legs D restrict all oral fluids correct answer C Elevate the patient legs rationale elevating the legs helps to reduce edema and improve Venus return in patients with heart failure increased physical activity may not be appropriate with increased symptoms tight compression stockings are not generally recommended in this case and fluid restriction should be individualized question 10 a patient with heart failure is taking lysil and complains of a persistent dry cough what is the nurse's best response a stop taking the medication and monitor your blood pressure at home B this is a common side effect let's monitor it for a few more weeks C inform your health care provider you might need a change in medication D increase your fluid intake to help sooth your throat correct answer C inform your healthc care provider you might need a change in medication rationale a persistent dry cough is a known side effect of AC Inhibitors like lysin April it may necessitate a change in medication which should be discussed with a health care provider stopping the medication abruptly or increasing fluid intake are not appropriate initial actions question 11 a nurse is providing discharge education to a patient with heart failure which statement by the patient indicates a need for further teaching a I will weigh myself every morning and keep a record B I should limit my fluid intake to 2 lers per day C if I feel short of breath I will take an extra dose of my diuretic D I will avoid high sodium foods like canned soups and fast food correct answer C if I feel short of breath I will take an extra dose of my diuretic rationale patients should not adjust their medication doses without consulting their health care provider self-adjusting diuretic doses can lead to electrolyte imbalances and dehydration the other statements indicate appropriate understanding of heart failure management question 12 which symptom is a nurse most likely to observe in a patient experiencing acute decompensated heart failure a Brady cardia B hypertension C pink frothy sputum D dry non-productive cough correct answer C pink froy sputum rationale pink froy sputum is a classic sign of pulmonary edema associated with acute decompensated heart failure indicating severe fluid congestion in the lungs the other symptoms are not typically associated with acute decompensated heart failure question 13 a patient with heart failure is prescribed beta blockers what is the primary reason for administering beta blockers in this patient a to increase heart rate B to improve renal function C to reduce the workload on the heart D to prevent fluid overload correct answer C to reduce the workload on the heart rationale beta blockers are prescribed in heart failure primarily to reduce the heart's workload by decreasing heart rate and contractility this helps to improve cardiac output and reduce symptoms they do not directly affect renal function or prevent fluid overload and typically do not increase heart rate question 14 a nurse is educating a patient with heart failure on dietary modifications which food item should the nurse advise the patient to limit a fresh fruits B whole grains C processed cheese D skinless chicken correct answer C processed cheese rationale processed cheese is high in sodium which can exacerbate fluid retention in heart failure patients limiting sodium intake is crucial in managing heart failure fresh fruits whole grains and skinless chicken are generally considered healthy choices for these patients question 15 a nurse is caring for a patient who was recently admitted for heart failure which of the following is a priority assessment a daily weight B Skin Integrity C ambulation ability D cognitive function correct answer a daily weight rationale monitoring daily weight is essential in managing heart failure as a rapid weight gain can indicate fluid retention and worsening of the condition while Skin Integrity ambulation ability and cognitive function are important they are not as immediately critical in heart failure management as monitoring for fluid overload question 16 a patient with heart failure is being educated on self-management which statement by the patient indicates a need for further education a I should report any increase in shortness of breath to my doctor B I will avoid taking over the counter IDs without consulting my doctor C if my legs are swollen at night I'll just sleep with extra pillows under them D I will follow a diet low in saturated fats and cholesterol correct answer C if my legs are swollen at night I'll just sleep with extra pillows under them rationale while elevating the legs can help reduce edema it is not a substitute for seeking medical advice when symptoms like leg swelling worsen as it might indicate decompensation of heart failure patients should be educated to report such changes to their health care provider the other statements reflect appropriate understanding of self-management and heart failure question 17 a nurse is caring for a patient with heart failure who is experiencing high anxiety levels which nurses intervention is most appropriate a administer anxiolytic medication as prescribed B encourage deep breathing and relaxation techniques C increase the frequency of blood pressure monitoring D restrict visitors to reduce stimulation correct answer B encourage deep breathing and relaxation techniques rational non-pharmacological interventions like deep breathing and relaxation techniques can be very effective in managing anxiety which is common in patients with heart failure while anxiolytics might be used they are not the first line intervention increasing blood pressure monitoring or restricting visitors might not directly address the anxiety issue question 18 during a home visit a nurse notices that a patient with heart failure has numerous cans of soup in the kitchen what is the most appropriate nursing action a instruct the patient to donate the canned soups to a food bank B educate the patient about the high sodium content in canned soups C recommend replacing canned soups with canned vegetables D ignore it as it is not relevant to the patient's heart condition correct answer B educate the patient about the high sodium content in caned soups rationale caned soups are typically high in sodium which can exacerbate heart failure symptoms educating the patient about the importance of a low sodium diet and identifying high sodium foods like canned soups is crucial in self-management of heart failure question 19 a patient with heart failure complains of increasing nocturnal dpia which intervention should the nurse prioritize a advise the patient to sleep in a recliner B increase diuretic dosage before bedtime C assess for other symptoms of fluid overload D provide supplemental oxygen throughout the night correct answer C assess for other symptoms of fluid overload rationale increase inreasing nocturnal dmia can be a sign of worsening heart failure and fluid overload the nurse should assess for other symptoms of fluid overload to determine the appropriate intervention while sleeping in a recliner and providing supplemental oxygen might help these are not initial interventions increasing diuretic dosage should be based on a physician's order question 20 a patient with heart failure is being discharged which statement by the patient indicates effective understanding of medication management a I will take my diuretic at night before bed B I will double my beta blocker dose if my symptoms worsen C I understand the importance of taking my medications as prescribed D I will stop taking my ACE inhibitor if I develop a cough correct answer C I understand the import importance of taking my medications as prescribed rationale adherence to prescribed medication regimens is crucial in managing heart failure the patient acknowledgement of this indicates an understanding of their medication management the other options reflect misunderstandings that could lead to adverse outcomes question 21 a nurse is caring for a patient with heart failure who is on a sodium restricted diet the patient expresses difficulty in adhering to the diet what is the most appropriate nursing response a it's important to strictly adhere to the diet to prevent Hospital readmission B let's explore some low sodium food options that you might enjoy C you can have high sodium foods occasionally if you're feeling well D non-adherence to the diet will lead to worsening of your heart failure correct answer answer B let's explore some low sodium food options that you might enjoy rationale collaborating with the patient to find palatable low sodium food options encourages adherence to the diet in a positive and patient- centered manner it's more effective than using fear of consequences or strict admonishments which may not be sustainable or motivating for the patient question 22 a patient with heart failure reports difficult sleeping at night due to frequent urination what should the nurse advise a take your diuretic medication in the morning instead of at night B reduce your fluid intake in the evening hours C it's a normal side effect try to sleep whenever you can during the day D increase your diuretic dose to reduce nighttime urination correct answer a take your diuretic medication in the morning instead of at night rationale adjusting the timing of diuretic medication to the morning can help reduce noctua and improve Sleep Quality this should be done in consultation with the healthc care provider reducing fluid intake in the evening may be helpful but should be balanced with the overall fluid needs increasing the diuretic dose is not appropriate without a physician's guidance question 23 during a follow-up visit a nurse finds that a patient with heart failure has not been adhering to the prescribed exercise regimen what is the most appropriate nursing action a reiterate the importance of exercise and the risks of non-compliance B explore the reasons for non-adherence and barriers to exercising C advise the patient to start with more intensive exercises to catch up D schedule more frequent follow-up visits to monitor exercise adherence correct answer B explore the reasons for non-adherence and barriers to exercising rationale understanding the patient barriers to exercising and reasons for non-adherence allows the nurse to provide tailored advice and support this patient- centered approach is more likely to result in positive behavior change compared to Simply reiterating the importance of exercise or increasing the intensity SL frequency of follow-ups question 24 a nurse is assessing a patient with heart failure which of the following is an early sign of worsening heart failure a sudden weight loss B decreased urine output C increased exercise tolerance D improved appetite correct answer B decreased urine output rationale decreased urine output can be an early sign of worsening heart failure indicating reduced kidney profusion due to decreased cardiac output sudden weight loss increased exercise tolerance and improved appetite are not typical early signs of worsening heart failure question 25 a patient with heart failure is being educated on self-monitoring for fluid overload which of the following should the nurse include in the teaching a check for pitting edema in your legs every evening B monitor for a dry hacking cough as a sign of fluid overload C weigh yourself once a week and record the weight D limit your fluid intake to one liter per day correct answer a check for pitting edema in your legs every evening rationale checking for pitting edema is a practical method for patients to monitor for fluid overload a dry hacking cough may not be a specific sign of fluid overload and heart failure weighing oneself should be done daily not weekly to promptly identify significant weight changes fluid intake recommendations should be individualized and not arbitrarily limited to one liter per day unless specific advised 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