This is an NCLEX select-all-that-apply practice question. This question provides a scenario about developing a nursing care plan for a patient with congestive heart failure and wants to know what nursing interventions will you include in the patient’s care plan.
This question is one of the many questions we will be practicing in our new series called “Weekly NCLEX Question”.
So, every week be sure to tune into our YouTube Channel for the NCLEX Question of the Week.
NCLEX Select-All-That-Apply (SATA) Practice Question
You’re developing a nursing care plan for a patient who has a diagnosis of congestive heart failure exacerbation. The patient has bilateral 2+ pitting edema in the lower extremities, extreme dyspnea on exertion, and crackles in the right and left lower bases of the lungs. The patient is prescribed Furosemide (Lasix) 40 mg IV twice a day. Which of the following options below will you include as nursing interventions for this patient? SELECT-ALL-THAT-APPLY:
A. Keep patient’s legs below heart level daily.
B. Weigh patient every morning on standing scale.
C. Patient will verbalize 3 health benefits to following a low sodium diet prior to discharge.
D. Maintain a daily fluid restriction of no more than 4 L of fluid per day.
E. Educate the patient daily about the importance of asking for help before ambulating.
F. Strictly monitor intake and output daily.
G. Monitor potassium levels daily.
This question is one of those “select-all-that-apply” scenarios where you will have to pick more than one answer…don’t you love those?!
For this particular question, we must select all the nursing interventions that will be included in our plan of care for this patient.
So, let’s breakdown the question: First, analyze the scenario! This patient has congestive heart failure with the following signs and symptoms: edema that is pitting in both the LE 2+, difficultly breathing when doing activity, and crackles in the lungs. Based on these findings and the patient’s diagnosis, this patient is in major fluid overload.
What is congestive heart failure? In a nutshell, it is where the heart, which is responsible for pumping blood throughout the body, isn’t pumping efficiently. Therefore, fluid starts to back up into the lungs and extremities (this can vary depending on the type of heart failure the patient has such as right or left-sided or both).
So, the patient’s heart is weak and they are literally drowning in their own fluid. So, as the nurse we need perform interventions that help alleviate this fluid overload.
Now, let’s analyze the medication the patient is prescribed: Furosemide (generic name)…Lasix (brand name)
What is Furosemide? It is a loop-diuretic. Therefore, this medication is going to work on the kidneys, specifically the loop of Henle (ascending limb), by stopping the limb from reabsorbing salt and potassium. This will pull extra water into the tubules which will exit the body as urine. Hence, it is going to remove excessive water in the body, so the patient is going to breathe easier and have decreased edema.
Now, ask yourself, what should I be monitoring while this patient is taking Lasix?
- Patient’s intake and output
- Daily weights
- Electrolyte levels…Sodium, Potassium levels..especially potassium (see why below)
- Kidney function
- Status of edema and crackles in the lungs…is it decreased?
- Is the patient’s dyspnea on exertion decreased?
- Monitoring diet…low sodium intake and fluid restriction of no more than 2 L per day or whatever the physician specifies.
Now, that we have analyzed the scenario, start thinking about our role as the nurse. What are we going to be doing for this patient who has fluid overload?
When I answer “select-all-that-apply” questions, I like to take each option and treat it as a True or False type questions. Therefore, let’s do this:
A. Keep patient’s legs below heart level daily. True or False
This statement is incorrect. We need to keep the patient’s legs ABOVE (not below) heart level daily. This will allow the fluid to easily go back to the heart to be pumped and prevent it from pooling in the legs.
B. Weigh patient every morning on standing scale. True or False
As the nurse you most definitely want to weigh your patient with congestive heart failure every morning with the same scale. Standing scales are the best..however, if the patient can’t stand a bed scale will work. Why do we monitor the patient’s weight so closely? To assess how well the patient is responding to treatment…are they retaining or losing fluid?
C. Patient will verbalize 3 health benefits to following a low sodium diet prior to discharge. True or False
This is a tricky option. Yes, this is something you would want a patient with congestive heart failure to verbalized BUT it is NOT a nursing intervention…it is a patient goal. This question wants to know the nursing interventions. However, if the statement said, “The nurse will educate the patient about 3 health benefits to following a low sodium diet prior to discharge”, this would be correct because it is a nursing intervention. So, always make sure you are selecting what the question is asking.
D. Maintain a daily fluid restriction of no more than 4 L of fluid per day. True or False
Patients with congestive heart failure are ordered by the physician to be on a fluid restriction, and as the nurse it is our responsibility to maintain/monitor the fluid restriction. However, 4 L is a lot of fluid to consume a day. Patients with CHF are ordered to consume no more than 2 L per day and sometimes it is less depending on the severity of the heart failure.
E. Educate the patient daily about the importance of asking for help before ambulating. True or False
This is a very important nursing intervention to include in the patient’s nursing care plan because this patient is at risk falls. Why? The patient’s respiratory system is already compromised along with the heart’s pumping ability, therefore, ambulating requires a lot of effort from the lungs and heart. The patient’s oxygen saturation could drop which will lead them to feeling dizzy, and this could lead to falling. In addition, since the patient is taking a diuretic, the body is experiencing fluid status changes which places the patient at risk for orthostatic hypotension. Furthermore, the swelling in the lower extremities make it hard to walk and this could lead to an unintentional fall.
F. Strictly monitor intake and output daily. True or False
The nurse definitely wants to strictly monitor the patient’s intake and output. Why? To make sure the patient isn’t consuming too much fluid compared to how much urine is being put out. We want the diuretics to do their job, and if the patient is consuming an excessive amount of fluid this cancels out the effect of the diuretics. In addition, it allows us to monitor the renal function. Loop-diuretics can cause renal failure and the nurse must make sure the patient is urinating at least 30 cc/hr.
G. Monitor potassium levels daily. True or False
Furosemide is notorious for causing the body to waste potassium. Remember it inhibits the ascending limb of the loop of Henle from reabsorbing potassium and salt. Therefore, the body wastes potassium, and the patient can experience hypokalemia. Most of the time if a patient is on Lasix, especially the IV route, a daily potassium level will be ordered by the physician. Therefore, it is very important the nurse monitors this level prior to administering subsequent doses of Lasix.
The answers are: B, E, F, G