Question 10 - Physiological Adaptation Practice Test for the NCLEX-RN Exam

A nurse is caring for a client with dilated cardiomyopathy who is hospitalized for an acute flare of congestive heart failure (CHF). The client has symptoms of fatigue, weakness, and dyspnea. The nurse notes peripheral edema as well as coolness and pallor in the distal extremities. Given this client’s physiologic status, which of the following nursing interventions would be indicated?
Select all that apply.

A. Teach and encourage the patient to perform vigorous exercise for 30 minutes once daily.
B. Teach and encourage the patient to perform coughing, deep breathing, and incentive spirometry exercises.
C. Provide appropriate analgesia for occurrences of chest pain and give supplemental oxygen as indicated per the practitioner’s orders.
D. Take proper precautions to protect the patient from falls and injuries during transfers and ambulation.
E. Elevate the lower extremities to reduce peripheral edema and improve circulation with the use of sequential devices of TED hose.

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