A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: A weight gain of 2 kg (4.4 lb) in 2 days can indicate fluid retention, which is a sign of worsening heart failure and should be reported. This rapid weight gain suggests a fluid overload, putting the client at risk for complications. A heart rate of 90/min is slightly elevated but not as concerning as a sudden significant weight gain. The serum potassium level of 4.0 mEq/L is within the normal range and does not directly indicate worsening heart failure. A heart rate of 76/min is within the normal range and does not raise immediate concerns related to heart failure.

Correct Answer: A

Rationale: When a patient refuses a blood transfusion for religious reasons, the healthcare provider should respect the patient's beliefs. It is crucial to uphold the patient's autonomy and right to make decisions about their care, even if the provider disagrees. Educating the patient on the importance of the transfusion may be appropriate in some cases, but the initial response should always be to respect the patient's decision. Notifying the healthcare provider is not necessary as the decision lies with the patient. Persuading the patient to accept the transfusion goes against the principle of respecting the patient's autonomy and beliefs.

Correct Answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

Correct Answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods when taking furosemide. Furosemide is a loop diuretic that can cause potassium loss, so consuming potassium-rich foods like bananas and oranges can help maintain adequate potassium levels. Choice A is incorrect because there is no need to avoid consuming dairy products. Choice C is incorrect because while fluid intake may need to be monitored, the general instruction is not to limit fluids to prevent dehydration. Choice D is incorrect because furosemide is usually best taken during the day to avoid disrupting sleep with frequent urination.

Correct Answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

Correct Answer: C

Rationale: When a patient is receiving IV potassium, it is crucial to monitor the IV site. Potassium can be irritating to the veins and may cause phlebitis or infiltration. Monitoring the IV site allows early detection of any potential complications. Checking urine output (Choice A) is important to assess kidney function but is not directly related to monitoring IV potassium. Blood pressure (Choice B) and respiratory rate (Choice D) are essential vital signs to monitor in general patient care but are not specific to monitoring IV potassium administration.

Correct Answer: B

Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.

Correct Answer: C

Rationale: The correct action the nurse should take for a client at risk for developing DVT is to apply sequential compression devices to the client's legs. This intervention helps prevent venous stasis by promoting circulation and reducing the risk of DVT. Encouraging the client to remain on bed rest (Choice A) can actually increase the risk of DVT due to immobility. Massaging the client's legs every 4 hours (Choice B) can dislodge blood clots and is contraindicated in DVT prevention. While administering anticoagulants as prescribed (Choice D) is a treatment for DVT, it is not a preventive measure for a client at risk.

Correct Answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.