Practice Question
A nurse is caring for a client who has heart failure.
Answer Choices:
Rationale:
🟦 Daily weights reflect fluid retention, which is the most accurate indicator of worsening or improving heart failure.
🟦 Increasing furosemide is essential, because the client has fluid overload evidenced by weight gain and declining oxygen saturation.
🟦 Fluid restriction reduces preload, helping control pulmonary and peripheral edema.
🟦 BNP of 400 indicates high cardiac strain, making diuresis and fluid restriction important interventions.
🟦 Maintaining oxygenation is critical, and interventions meant to improve perfusion (diuresis + oxygen) directly support stabilization.
Begin a 24-hr urine collection
🟦 This test does not address acute fluid overload, which requires immediate management.
🟦 The client’s priority is stabilizing respiratory and cardiac status, not collecting long-term urine output data.
Decrease oxygen to 1 L/min
🟦 Oxygen saturation is worsening, so lowering oxygen would further reduce perfusion.
🟦 HF with pulmonary congestion requires maintaining or increasing oxygen, not reducing it.
Hold the client’s metoprolol
🟦 The client has atrial fibrillation with HR >110, so metoprolol is needed for rate control.
🟦 Stopping metoprolol increases risk of tachyarrhythmias and decreased cardiac output.
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This question is from RN Adult Medical Surgical 2023 Dec which contains 78 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 0