1. A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the oxygen per protocol. Which of the following actions should the nurse take first?
a. Check oxygen saturation with pulse oximeter.
b. Notify the primary care provider.
c. Auscultate the lungs, listening for increased crackles.
*d. Assist the client into high-Fowler’s position.
2. When planning discharge teaching for a client who has heart failure, which of the following actions should the nurse include in the teaching?
a. Weigh patient weekly and notify the provider if there is a weight gain of 3 lb in 2 weeks.
b. Take diuretics in the evening to allow for interrupted sleep.
*c. Conserve energy; the client should schedule rest periods between activities.
d. Get pneumonia vaccine and flu shot yearly.…show more content… Evaluating the patient’s response to normal activities of daily living.
*b. Checking the patient’s blood pressure and pulse rate after ambulation.
c. Determining which self-care activities the patient can do independently.
d. Assisting the patient in choosing a diet that will improve strength.
20. A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first?
a. Take a full medication history
*b. Administer oxygen to the patient.
c. Apply a cardiac monitor to the client
d. Provide emotional support to the client.
21. The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client’s morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
a. Weigh the client every morning.
b. Maintain accurate intake and output records.
c. Restrict fluids to 1500 mL/day.
*d. Administer furosemide (Lasix) 40 mg IV
