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A nurse is caring for a client who has heart failure and
reports increased shortness of breath. Which of the
following actions should the nurse take first?
A. Obtain the clients weight
B. Assist the client into high-fowlers position
C. Auscultate lung sounds
D. Check oxygen saturation with pulse oximeter -
ANSWER-B. Assist the client into high-fowlers position
,A nurse is teaching a client who has HF and new
prescriptions for furosemide and digoxin. Which of the
following information should the nurse include. Select all
that apply
A. Weight daily, first thing each morning
B. Decrease intake of potassium
C. Expect muscle weakness while taking digoxin
D. Hold digoxin if HR is less than 70/min
E. Decrease sodium intake - ANSWER-A. Weight daily,
first thing each morning
E. Decrease sodium intake
,A nurse is completing the admission assessment of a
client who has suspected pulmonary edema. Which of the
following manifestations are expected findings? Select all
that apply
A. Tachypnea
B. Persistent Cough
C. Increased urinary output
D. Thick, yellow sputum
E. Orthopnea - ANSWER-A. Tachypnea
B. Persistent Cough
E. Orthopnea
, A nurse is talking with a client who has class I HF and
asks about obtaining a ventricular assist device (VAD).
Which of the following statements should the nurse take?
A. "VADs are only implanted during heart transplantation"
B. "A VAD helps to pace the heart"
C. "VADs are used when heart failure is not responsive to
medications"
D. " A VAD is useful for clients who also have a chronic
lung issue" - ANSWER-C. "VADs are used when heart
failure is not responsive to medications"
A nurse is providing discharge teaching for a client who
has HF and is on fluid restriction 2,000 mL/day. The client