A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Correct Answer: A

Rationale: The correct answer is A: Fever. Fever is an early indicator of infection as it is the body's natural response to fighting off pathogens. When the body detects an infection, it raises its temperature to create an inhospitable environment for the pathogens. Pain at the surgical site (B) is common post-operatively but may not necessarily indicate infection. Redness at the incision site (C) can be a sign of inflammation but is not specific to infection. Increased heart rate (D) can occur due to various reasons post-operatively, not just infection. Fever is a systemic response and a more reliable early indicator of infection in this context.

Correct Answer: B

Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.

Correct Answer: C

Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.