NUR 242 Exam 3

Which statement by a client is consistent with a diagnosis of heart failure?

"I have trouble breathing when I climb a flight of stairs.

Which client statements indicate that the teaching about furosemide is understood? Select all that apply. One, some, or all responses may be correct.

"I need to change my position slowly." "I should eat more food that is high in potassium."

Which statement by a client who is seen for follow-up in the heart failure clinic is most important for the nurse to communicate to the health care provider?

"I wake up at night short of breath"

A client who takes furosemide and digoxin reports to the nurse that everything looks yellow. Which response by the nurse is most appropriate?

"I will hold the medication until I consult with your health care provider.

A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide

"The medication may need to be discontinued. Come to the clinic this afternoon."

The nurse teaches the parents of a 4-year-old child about the administration of digoxin elixir twice a day. Which statement indicates to the nurse the parents need further teaching?

"We should give the digoxin twice a day, at breakfast and dinner

A client with heart failure weighed 175 lb (79.4 kg) yesterday, and today's weight is 181 lb (82.1 kg). How many milliliters of fluid has the client retained? . ___mL

2700 ml

According to developmental norms for a 5-year-old child, the nurse would hold digoxin if an apical heart rate falls below which number?

70 beats/min

Which prophylactic medication would the nurse anticipate administering to a pregnant client who has mitral valve stenosis during the intrapartum period?

Antibiotic

Which topic would be included in discharge teaching for a 22-year-old client who has had mitral valve replacement with a mechanical valve?

Anticoagulation therapy

Which assessment will the nurse conduct before administering digoxin to a client?

Apical heart rate

When caring for an older client who has had multiple recent hospital admissions for heart failure, which action would the nurse take first?

Ask the client about medication use and activity level at home

When an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first?

Assess the client's heart and lung sounds

A client who has been admitted with pulmonary edema and received furosemide intravenously needs to void. Which action by the nurse would be best?

Assist the client to a bedside commode.

Which action would the nurse take first when a client with heart failure has an episode of paroxysmal nocturnal dyspnea (PND)?

Assist the client to sit on the edge of the bed

An infant is born with a life-threatening congenital heart defect and is admitted to the neonatal intensive care unit. Which is the priority nursing intervention at this time?

Assisting the parents with the grieving process

When a client with heart failure reports a 9-pound (4-kilogram) weight gain in the past 2 weeks, which assessment is the priority?

Auscultate breath sounds.

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. Which nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?

Auscultating breath sounds

Which suggestion would the nurse make for a client with heart failure?

Avoid emotionally stressful situations

A client was prescribed furosemide. The nurse would instruct the client to include which food in the diet?

Bananas

Which medication prescribed for a client with an acute episode of heart failure would the nurse question?

Beta blocker

Heart failure develops in a 4-month-old infant with a congenital heart defect, and the infant exhibits marked dyspnea at rest. Which assessment finding would the nurse expect in this infant?

Bilateral crackles

The heartbeat assessment of four clients is given below. Which client is at an increased risk for right-sided heart failure?

Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm. This client is at risk for right-sided heart failure. One-sided pressure elevation is caused by obstruction, as observed in clients B, C, and D.

A client with hypertensive heart disease who had an acute episode of heart failure is to be discharged on a regimen of metoprolol and digoxin. Which outcome would the nurse anticipate when metoprolol is administered with digoxin?

Bradycardia

Which lifestyle advice does the nurse give to a client when oral digoxin therapy is initiated? Select all that apply. One, some, or all responses may be correct.

Bran can decrease digoxin absorption. Digoxin should not be taken with hawthorn supplements. Ginseng may cause a dangerous increase in digoxin levels in the blood. Medications that lower serum potassium or magnesium can cause digoxin toxicity.

The nurse is administering 40 mg of furosemide intravenously. Which sensation reported by the client would the nurse consider when determining that it is being administered too quickly?

Buzzing ears

A 2-month-old infant with the diagnosis of heart failure is discharged with a prescription for oral digoxin 0.05 mg every 12 hours. The bottle of digoxin is labeled "0.05 mg/mL." Which item would the nurse teach the mother to use when administering the medication?

Calibrated syringe

Which clinical finding indicates that a client taking digoxin may have developed digoxin toxicity?

Cardiac dysrhythmias

Which nursing interventions promote safe administration of digoxin in a child diagnosed with heart failure? Select all that apply. One, some, or all responses may be correct.

Checking for compliance with the client's medication regimen Monitoring the client's serum potassium and magnesium levels regularly Calculating the correct dosage form, prescribed amounts, and the prescriber's prescription Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly

The nurse is caring for a child receiving furosemide for pulmonary edema. Which nursing intervention(s) would the nurse implement? Select all that apply. One, some, or all responses may be correct.

Checking the child's weight every day Calculating the dose of medication as carefully as possible Assessing the child regularly to help prevent electrolyte loss

When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client?

Climbing a flight of stairs to the bedroom

When caring for a client with heart failure, which type of lung sounds would the nurse expect to hear?

Crackles

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct.

Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds

When caring for a client with a diagnosis of right ventricular heart failure, the nurse expects which assessment findings? Select all that apply. One, some, or all responses may be correct.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

When assessing a client with chronic heart failure, which clinical finding would the nurse expect to find?

Dependent edema in the evening

A client has been given a prescription for furosemide 40 mg every day in conjunction with digoxin. Which concern would prompt the nurse to ask the health care provider about potassium supplements?

Digoxin toxicity occurs rapidly in the presence of hypokalemia

Which assessment findings are consistent with a client diagnosis of right-sided heart failure? Select all that apply. One, some, or all responses may be correct.

Distended abdomen Dependent edema Decreased appetite

Which finding would the nurse expect when caring for a client with right-sided heart failure?

Distended neck veins

A client with left ventricular heart failure and supraventricular tachycardia is prescribed digoxin 0.25 mg daily. Which changes would the nurse expect to find if this medication is therapeutically effective? Select all that apply. One, some, or all responses may be correct.

Diuresis Decreased edema Decreased pulse rate

When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. One, some, or all responses may be correct.

Dyspnea Crackles Frequent cough

When a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32 breaths/minute, which action would the nurse take first?

Elevate the head of the bed to 75 degrees.

When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. One, some, or all responses may be correct.

Extreme fatigue Coughing at night Difficulty breathing

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct.

Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain

The nurse explains to a pregnant client with a class II heart failure that in pregnancy the cardiac system is most compromised during which time?

First 2 days after the birth

An infant with a congenital heart defect is in heart failure and is receiving daily weight measurements. Which complication of heart failure would daily weights help monitor?

Fluid retention

The nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply. One, some, or all responses may be correct.

Foramen oval Ductus arteriosus

Hydrochlorothiazide (HCTZ) has been prescribed for a client with hypertension. The client reports hearing that furosemide is more effective and requests a prescription change. How will the nurse respond?

HCTZ has fewer side effects

Which action would the nurse take first when a client who has heart failure reports fatigue and has an increase in heart rate from 90 beats/minute to 120 beats/minute while ambulating?

Have the client sit down and rest

A health care provider prescribes milrinone for a client with congestive heart failure. Which action would the nurse perform first?

Have the prescription, dosage calculations, and pump settings checked by a second nurse

A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies that which items on the client's care plan are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply. One, some, or all responses may be correct.

Help the client ambulate when required. Monitor the client's vitals every 30 minutes Administer adequate oral fluids to the client

A client is taking furosemide. At each clinic visit, the nurse will assess for which adverse effect?

Hyporeflexia

The nurse provides discharge teaching to a client who has received prescriptions for digoxin, furosemide, and a 2-g sodium diet. Which statement from the client indicates that further teaching is needed?

I can use a little table salt on my food as long as I do not use it when cooking food

A client admitted for mitral valve surgery tells the nurse, "I am not worried at all about the surgery!" Which response by the nurse is best?

I think you may still have questions about the surgery.

After the nurse has taught about self-care to a client who has had a mitral valve replacement, which client statement indicates a need for more education?

I will start a vigorous aerobic exercise program

Digoxin is prescribed for a client. Which therapeutic effect of digoxin would the nurse expect?

Increased contractile force of the myocardium

Which education would the nurse teach the parents of an infant with a cardiac defect about an early sign of heart failure?

Increased heart rate

Which early sign of heart failure would the nurse recognize in an infant who has a congenital heart defect with left-to-right shunting of blood?

Increased respiratory rate

How would anxiety affect outcomes for a client with heart failure?

Increases the cardiac workload

When caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles, which prescribed action would the nurse question?

Infuse normal saline at 100 mL/h

Which intervention would the nurse use after observing that a 6-month-old child lies quietly, rarely smiles or babbles, and has his basic needs barely met by the primary caregiver, who is a grandparent with chronic heart failure?

Initiate a referral for assessment of home health and schedule a family conference.

The nurse provides medication discharge instructions to a client who received a prescription for digoxin. Which statement by the client leads the nurse to conclude that the teaching was effective?

It will be important to check my pulse rate daily.

When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb (2.7 kg), which nursing action has the highest priority?

Listen to the client's breath sounds

A health care provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in which part of the renal system?

Loop of Henle

In which components of the nephron unit does furosemide decrease fluid reabsorption? Select all that apply. One, some, or all responses may be correct.

Loop of Henle, distal tubules, and proximal tubules

Which diet choices by a client who has heart failure indicate that the nurse's teaching about diet has been effective? Select all that apply. One, some, or all responses may be correct.

Low sodium- Lean steak Fruit salad Broiled chicken Roasted potatoes

A client takes furosemide and digoxin for heart failure. Why would the nurse advise the client to drink a glass of orange juice every day?

Maintaining potassium levels

Which treatment would the nurse anticipate when caring for an infant with heart failure?

Medications that are prescribed for both children and adults

Which action would the nurse manager employ during implementation and evaluation of a quality improvement project to decrease hospital readmissions for heart failure clients? Select all that apply. One, some, or all responses may be correct.

Meeting regularly with staff throughout project implementation Using readmission data for heart failure clients to evaluate project effectiveness Collaborating with staff to address continuing high readmission rates post-project implementation Ensuring that staff are provided time to participate in development and implementation of the new project Coaching staff on effective implementation of the transition of care for heart failure clients being discharged

When a client with type 1 diabetes develops heart failure, digoxin is prescribed. Which nursing action is important to include when planning care?

Monitor the client for cardiac dysrhythmias.

Which nursing interventions are important when caring for clients receiving intravenous (IV) digoxin? Select all that apply. One, some, or all responses may be correct.

Monitor the heart rate closely. Check the blood levels of digoxin. Monitor the serum potassium level

A child with a congenital heart defect has a cardiac catheterization. Which is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site

A client who has been diagnosed with a myocardial infarction receives digoxin, fluoxetine, morphine, and docusate sodium. Which medication would the nurse identify as a risk factor for straining due to constipation?

Morphine

When assessing a client who has aortic stenosis and is scheduled for aortic valve replacement, which finding by the nurse is most important to communicate to the health care provider?

Multiple dental caries

A client is receiving furosemide. For which sign of hypokalemia will the nurse monitor client?

Muscle weakness

Digoxin and verapamil are prescribed to manage a client's cardiac dysrhythmia. The nurse will monitor the client for signs and symptoms of which adverse effect?

Myocardial depression

During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? Select all that apply. One, some, or all responses may be correct.

Nasal flaring Sternal retractions Grunting respirations

Digoxin is prescribed for a client with heart failure. The nurse will assess for which signs and symptoms that indicate digoxin toxicity? Select all that apply. One, some, or all responses may be correct.

Nausea Yellow vision Irregular pulse

Which action would the nurse take when assessing an infant on digoxin who has an apical pulse of 88 beats per minute?

Notify the health care provider immediately

What action is most appropriate for the nurse to take for a client who began receiving furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L (2.8 mmol/L)?

Notify the primary health care provider of the critically low result

Which care plan would the nurse implement for an infant admitted to the pediatric unit with the diagnosis of heart failure?

Offer the infant small, frequent feedings

While auscultating the heart, a health care provider notices S 3 heart sounds in four clients. Which client is at highest risk for heart failure?

Older adult client

The nurse advises a client receiving furosemide about potassium intake. Which fruits would the nurse encourage the client to eat? Select all that apply. One, some, or all responses may be correct.

Orange Banana Dried fruit

Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse?

Oxygen saturation 86%

Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective?

Oxygen saturation per pulse oximetry is 99%

A client with heart failure reports waking suddenly and feeling short of breath during the night. How will the nurse document this information?

Paroxysmal nocturnal dyspnea

When a client with heart failure reports frequent sudden waking during the night with shortness of breath, how will the nurse document this finding?

Paroxysmal nocturnal dyspnea

When a client with a history of heart failure on daily weights has a 4-pound (1.8-kilogram) weight gain since the previous day, which action would the nurse take next?

Perform a head-to-toe assessment.

Which assessment finding is a late sign of heart failure?

Peripheral edema

The nurse preceptor is evaluating the nurse who is preparing to administer digoxin intravenously (IV) to a client. Which intervention by the nurse would require the preceptor to stop the nurse?

Piggybacking the digoxin in an existing infusion

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention?

Place client in a high-Fowler position.

Which would the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?

Place the client in the orthopneic position

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin?

Potassium level of 2.3 mEq/L (2.3 mmol/L)

An infant with a diagnosis of heart failure is being given furosemide twice a day. Which laboratory value would the nurse report to the health care provider?

Potassium of 3.0 mEq/L (3.0 mmol/L)

A client, who is currently taking digoxin 0.125 mg in the morning and alprazolam 0.5 mg twice a day, is prescribed donepezil 5 mg daily for early dementia of the Alzheimer type. Which instruction would the nurse include when teaching the client's spouse about medication administration?

Prefill a weekly medication box with the medications for the client to self-administer."

Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider?

Premature ventricular contractions

Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and heart failure?

Providing small, frequent feedings

When a client with heart failure is to be discharged and tells the nurse that there are no family members who can help with care at home, which action would the nurse take first?

Question the client about current support systems

The parents of a preschooler with a congenital heart defect asks the nurse why their child squats after exertion. Which rationale would the nurse provide the parents?

Reduces how hard the heart must work

Which advice will the nurse include when teaching a client about digoxin for left ventricular failure?

Report increasing fatigue

A client is given a loading dose of digoxin and placed on a maintenance dose of digoxin 0.25 mg by mouth daily. Which responses would the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

Resolution of heart failure

When the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure, the client becomes irritable and asks why bed rest is needed. Which response by the nurse is best?

Rest reduces the amount of work your heart has to do right now."

Which nursing action is a priority before administering prescribed furosemide?

Review the potassium level results.

The nurse taught a client with heart failure who is scheduled for discharge about how medications, diet, and exercise improve activity tolerance. During a follow-up visit, the nurse finds that the client has learned how to adapt his or her exercise prescription to increase activity tolerance. Which theory did the nurse follow to achieve this positive outcome?

Roy's theory

A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. Which position would the nurse encourage the client to assume?

Semi-Fowler

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema?

Shift of fluid into the interstitial spaces

The nurse assesses a newborn and observes central cyanosis. Which type of congenital heart defect usually results in central cyanosis?

Shunting of blood from right to left

In which position would the nurse place a 5-week-old infant who has difficulty breathing and feeding related to a suspected congenital heart defect?

Side-lying, with the upper body elevated

The nurse is providing discharge medication teaching to a client who will be taking furosemide and digoxin after discharge from the hospital. Which information is important for the nurse to include in the teaching plan?

Signs and symptoms of digoxin toxicity

The clinic nurse receives a call from the mother of an infant prescribed digoxin. The mother reports she forgot whether she gave the morning dose of digoxin. Which response by the nurse is most appropriate?

Skip this dose and give it at the next prescribed time.

A client with heart failure is to receive digoxin. Which therapeutic effect is associated with this medication?

Slows and strengthens cardiac contractions

Which topics will the nurse include in discharge teaching for a client who has had a mitral valve replacement with a mechanical valve? Select all that apply. One, some, or all responses may be correct.

Symptoms of infection Use of pain medications Purpose of anticoagulant medications

Which sign or symptom indicates that the client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is experiencing cardiac difficulties?

Syncope on exertion

Which sign would indicate possible heart failure in a client with heart disease in the immediate postpartum period?

Tachypnea

Which topics would be included when teaching a client with heart failure who will be discharged with a new prescription for digoxin? Select all that apply. One, some, or all responses may be correct.

Take your radial pulse daily and write it down. Notify the health care provider if you develop any vision changes Call the health care provider if your pulse is irregular or less than 60 beats/minute

When the home care nurse calls to make an appointment for the initial visit with a client who has heart failure, the client reports that many family members are visiting today and requests that the nurse wait a week for the appointment. Which response by the nurse is best?

Tell the client that it might be helpful to talk with family members during the initial visit.

Which parent education would the nurse provide as rationale for gavage feedings in an infant with congestive heart failure?

The energy that would have been expended on suckling is conserved

A neonate with heart failure is prescribed furosemide. Which changes to the dosage or time intervals between doses would the nurse make?

The time between doses should be lengthened

Furosemide has been prescribed as part of the medical regimen for a client with hypertension. Which client statement indicates a need for medication education

This can decrease my vitamin K level.

intravenous furosemide has been prescribed for a client with severe edema and hypertension. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply. One, some, or all responses may be correct

Tinnitus Weakness Leg cramps

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct.

Unusual fatigue Dependent edema Nocturnal dyspnea

A preterm infant is started on digoxin and furosemide for persistent patent ductus arteriosus. Which nursing assessment provides the best indication of the effectiveness of the furosemide?

Urine output exceeds fluid intakes

When the clinic nurse is teaching a group of clients with heart failure (HF) about dietary interventions to prevent fluid overload, which topic will be included?

Use of fresh or frozen vegetables instead of canned ones / low sodium

Which statement made by the nursing student requires correction regarding the effect of applying the Roy adaptation model on improved functional status in clients with heart failure?

Use of literature resources supports practical-based nursing interventions."

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

Using several pillows at night to sleep

A health care provider prescribes digoxin for a client. The nurse teaches the client to be alert for which common early indication of acute digoxin toxicity?

Vomiting

The nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. Which sign of digoxin toxicity would the nurse monitor for?

Vomiting

When caring for a client who was admitted with heart failure, which action by the nurse will be most effective in determining whether the client's fluid overload is improving?

Weighing the client

The nurse provides teaching to a client who is being discharged after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor for which indication of right-sided heart failure?

Weight gain

A client is receiving furosemide to relieve edema. The nurse will monitor the client for which responses? Select all that apply. One, some, or all responses may be correct.

Weight loss Excessive loss of potassium ions

Which assessment finding would indicate improvement in a 4-month-old infant admitted to the pediatric unit with a diagnosis of congestive heart failure?

Weight loss during next 2 days

How can the nurse describe heart failure to a client?

an inability of the heart to pump blood in proportion to metabolic needs

The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining?

fluid retention

A client is receiving furosemide to relieve edema. The nurse will monitor the client for which adverse effect?

hypokalemia

Which landmark is correct for the nurse to use when auscultating the mitral valve?

left fifth intercostal space at the midclavicular line

When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?

yellow vision

When preparing to give medications to a client, the nurse notes a prescription for digoxin 2.5 mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which action would the nurse take?

Consult with the primary health care provider

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct.

Diuretics Low-salt diet Daily weight checks Fluid restriction Intake and output Oxygen administration

Which feeding education would the nurse provide the parent of a 2-month-old infant with the diagnosis of heart failure?

Feed slowly while allowing time for adequate periods of rest

Which would the nurse avoid in an infant with a congenital heart defect after cardiac catheterization?

Performing range-of-motion exercises

Which method would the nurse use to weigh a 2-month-old in heart failure with practitioner orders for semi-Fowler positioning?

Placing the infant in an infant seat, recording the weight, and then subtracting the weight of the seat

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate?

TB adversely affects older adults with chronic illness

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do?

Change positions slowly

When the nurse is obtaining the health history for a client with mitral valve stenosis, which question will be most relevant to ask?

Did you ever have strep throat during childhood

An infant with congenital heart disease is prescribed digoxin and furosemide upon discharge. Which sign would the nurse instruct the parents to be alert for?

Difficulty feeding with vomiting

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet?

Fluid retention

Which parameter would the nurse assess in a client with right-sided heart failure? Select all that apply. One, some, or all responses may be correct.

Fluid volume

A child with pulmonary edema is treated with opioids and furosemide. Which nursing interventions would the nurse perform to promote safe medication administration? Select all that apply. One, some, or all responses may be correct.

Following the principle of atraumatic care Administering oral drugs with food or snacks Documenting the client's age, weight, and height

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factors that may have contributed to the ankle swelling? Select all that apply. One, some, or all responses may be correct.

Intake of salty foods Medication compliance Recent travel

When reviewing laboratory results for a client with heart failure who has been receiving furosemide daily, the nurse notes a blood urea nitrogen (BUN) of 42 mg/dL (15.2 mmol/L) and a creatinine of 1.1 mg/dL (97 mcmol/L). Which action by the nurse is a priority?

Notifying the health care provider about the results

The nurse is caring for a client who is admitted to the hospital for medical management of heart failure and severe peripheral edema. Which clinical indicator associated with unresolved severe peripheral edema would the nurse initially assess?

Tissue ischemia

The nurse is reviewing medication instructions with parents of an infant receiving digoxin and spironolactone. Which parental response indicates instructions have been understood?

Vomiting should be reported to the health care provider