Physiological Adaptation Practice Question

Question

The nurse is caring for a client with diabetes and is focused on heart failure exacerbation scenario 2. Which nursing action is most appropriate?

Answer choices

  1. A. Delay assessment until the next scheduled round if the client is not calling for help.
  2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
  3. C. Monitor weight gain, dyspnea, edema, and response to diuretics.
  4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

C. Monitor weight gain, dyspnea, edema, and response to diuretics.

Explanation

The priority action for heart failure exacerbation is to monitor weight gain, dyspnea, edema, and response to diuretics. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

  • Difficulty: medium
  • Domain: Physiological Adaptation
  • Objective: heart failure exacerbation

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