Which condition alerts the nurse to assess a patient for ...

[Sufayan.ah]

Which condition alerts the nurse to assess a patient for worsening heart failure?
 
  a. Blood pressure of 106/40 mm Hg
  b. Pounding headache
  c. Foul urine odor
  d. Ankle swelling

Question 2

Which condition requires that the nurse withhold a drug dose for a patient with a feeding tube?
 
  a. The drug is in the form of a capsule.
  b. The drug volume is greater than 20 mL.
  c. Carbon dioxide is detected from the feeding tube.
  d. The patient is unconscious and unable to swallow.

[lorealeza]

Answer to Question 1

D
Ankle swelling is associated with heart failure, although other conditions also can cause it. If this is a new symptom or is occurring even when the patient is not spending a lot of time sitting or standing, the nurse should assess the patient for other symptoms of heart failure. Although the blood pressure is not high, the pulse pressure is wide which does not indicate failure. A pounding headache is most associated with elevated blood pressure. Foul-smelling urine is associated with urinary tract infection.

Answer to Question 2

C
When carbon dioxide comes from the feeding tube, the tube is in the trachea rather than the sto-mach. Using this compromised feeding tube for drug administration would result in drug place-ment into the lungs instead of the stomach, which can cause serious complications.

[Sufayan.ah]

TYSM

[ebonylittles]

Gracias!