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Practice Question

A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

Answer Choices:

Correct Answer:

Limit fluid intake to 2 liters/day.

Rationale:

🟢 Heart failure patients often experience fluid overload, which can worsen pulmonary congestion and edema.

🟢 Limiting fluid intake to 2 liters/day helps prevent volume overload and reduces the strain on the compromised heart.

🟢 Fluid restriction, along with sodium control, is a standard non-pharmacologic management strategy for heart failure.

🟢 Accurate daily weights and intake/output monitoring help assess fluid status and detect early signs of fluid retention.

🟢 Patient education on fluid management is crucial to prevent decompensation and repeated hospital admissions.

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This question is from Adult Health-Viterbo University which contains 46 questions.

More Questions from This Exam
A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Answer Choices:

A. Elevate the head of the bed immediately and notify the provider
B. Administer PRN tylenol for the patient's headache
C. Recheck all of the patient's vital signs
D. Elevate the patient's knees and lower the head of the bed
A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Answer Choices:

A. Assess the level at which the client has intact sensation
B. Determine the level at which the client has retained mobility
C. Monitor respiratory effort and oxygen saturation level
D. Check the blood pressure and pulse for signs of spinal shock
A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Answer Choices:

A. Flaccid paralysis and lack of sensation below the level of the injury
B. Hypotension, bradycardia, and warm extremities
C. Presence of hyperactive reflex activity below the level of the injury
D. Severe headache, hypertension, and flushed face
From Exam
Adult Health-Viterbo University

46 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: ATI Exam(s)
  • Domain: RN ATI Adult Health
  • Answer Choices: 4
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