which of the following is a priority intervention for a patient with heart failure
Logo

Nursing Elites

HESI RN

Evolve HESI Medical Surgical Practice Exam Quizlet

1. Which of the following is a priority intervention for a patient with heart failure?

Correct answer: B

Rationale: Administering oxygen is a priority intervention in heart failure because it helps improve oxygenation, alleviate hypoxemia, and reduce the workload on the heart. Oxygen therapy is crucial in managing acute heart failure exacerbations. While diuretics (Choice A) are commonly used in heart failure to reduce fluid overload, administering oxygen takes precedence due to its immediate impact on oxygen delivery. Beta-blockers (Choice C) and vasodilators (Choice D) are also important in heart failure management, but in the acute setting, ensuring adequate oxygen supply is the priority.

2. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action indicates the UAP needs additional teaching?

Correct answer: B

Rationale: The correct action that indicates the UAP needs additional teaching is choice B, 'Changing the client’s incontinence brief when wet.' Habit training is a technique used to manage incontinence, and it is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training, which involves scheduled toileting and promoting bladder control. Choices A, C, and D are appropriate actions that support the client’s care: toileting the client after meals, encouraging fluid intake, and documenting incontinence episodes are all important aspects of managing incontinence and monitoring the client's condition.

3. A patient asks the nurse about taking calcium supplements to avoid hypocalcemia. The nurse will suggest that the patient follow which instruction?

Correct answer: A

Rationale: The correct answer is to take a calcium and vitamin D combination supplement. Vitamin D enhances the absorption of calcium in the body, making it an essential component for calcium utilization. Choice B is incorrect because calcium and phosphorus have an inverse relationship, where an increased level of one mineral decreases the level of the other, so taking them together may not be beneficial. Choice C is incorrect because antacids often contain magnesium, which can promote calcium loss instead of absorption. Choice D is incorrect because aspirin can alter vitamin D levels and interfere with calcium absorption, so it is not recommended when taking calcium supplements.

4. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and complaining of a dry mouth. Which intervention should the nurse implement?

Correct answer: A

Rationale: Assisting the client to an upright position is the most appropriate intervention in this scenario. An upright position helps optimize lung expansion and aids in improving ventilation, which can alleviate shortness of breath. This position also assists in reducing anxiety by providing a sense of control and comfort. Administering a sedative (Choice B) may further depress the respiratory drive in a client with COPD and should be avoided unless absolutely necessary. Applying a high-flow Venturi mask (Choice C) may be indicated later based on oxygenation needs, but the immediate focus should be on positioning. Encouraging the client to drink water (Choice D) may not directly address the respiratory distress and anxiety experienced by the client.

5. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?

Correct answer: D

Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.

Similar Questions

A client who is postmenopausal and has had two episodes of bacterial urethritis in the last 6 months asks, “I never have urinary tract infections. Why is this happening now?” How should the nurse respond?
Which of the following interventions is most appropriate for a patient with acute pancreatitis?
After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?
The nurse is preparing to give a dose of oral clindamycin (Cleocin) to a patient being treated for a skin infection caused by Staphylococcus aureus. The patient has experienced nausea after several doses. What should the nurse do next?
After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

Access More Features

HESI RN Basic
$69.99/ 30 days

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

HESI RN Premium
$149.99/ 90 days

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

Other Courses