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    Ati pn adult medical surgical 2023 proctored exam

    A nurse is caring for a client who has heart failure. A nurse is caring for a client. After reviewing the findings above, which of the following actions should the nurse take? For each potential provider's prescription, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

    Explanation & Rationale

    Place the client on 24-hr urine collection: This is appropriate to monitor kidney function, fluid balance, and response to diuretics in a client with heart failure, especially with rapid weight gain. Place on sodium restriction of less than 1,500 mg per day: Sodium restriction is standard in heart failure management to prevent fluid retention and reduce the risk of worsening edema and hypertension. Request for an increased dosage of furosemide: The client shows weight gain (1.8 kg in 24 hr) and low oxygen saturation, suggesting fluid overload. Increasing the diuretic is an expected intervention to remove excess fluid. Decrease the client's oxygen to 1 L/min via nasal cannula: The client’s oxygen saturation is 90% on 2 L/min, indicating hypoxemia. Reducing oxygen would worsen tissue oxygenation and is contraindicated. Weigh the client daily: Daily weight monitoring helps detect early fluid retention or loss, which is critical in managing heart failure exacerbations. Request to hold the client's metoprolol: Holding a beta-blocker without a clear contraindication (e.g., severe bradycardia, hypotension, or acute decompensation) is unnecessary. Continuing metoprolol helps control heart rate and manage atrial fibrillation.

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