Condition most likely experiencing:

The client exhibits classic symptoms of left-sided heart failure, including dyspnea, nocturia, crackles, a dry hacking cough (worse at night), S3 gallop, and fatigue.

Low blood pressure (98/50 mm Hg), tachycardia (112/min), tachypnea (28/min), and oxygen saturation of 88% indicate poor cardiac output and pulmonary congestion.

Elevated BNP (410 pg/mL; normal <100 pg/mL) confirms heart failure.

The atrial fibrillation on ECG is a common complication of heart failure, further worsening cardiac function.

Actions to take:

Administer supplemental oxygen: The client’s SpO2 is 88%, indicating hypoxia. Oxygen therapy will improve oxygenation and reduce respiratory distress.

Elevate the head of the client’s bed: This helps reduce pulmonary congestion and improve breathing by promoting lung expansion.:

Parameters to monitor:

Weight: Daily weights are the best indicator of fluid retention and effectiveness of diuretic therapy. Sudden weight gain suggests worsening heart failure.

Urine output: Low urine output may indicate worsening heart failure and poor renal perfusion. Increased urine output after treatment suggests effective fluid removal.

Oxygenation:

The client's SaO₂ is 90% on 2 L/min via nasal cannula, which indicates impaired oxygenation. The client is experiencing rapid, labored breathing, suggesting respiratory distress. Cyanosis (bluish tint to extremities) and mottled skin indicate poor oxygen delivery to tissues. Addressing oxygenation first is critical to prevent worsening hypoxia and potential respiratory failure.

Blood Pressure:

The client has hypotension (74/50 mm Hg), likely due to malnutrition, dehydration, and inadequate caloric intake. Weak pulses, cold skin, and poor turgor suggest circulatory compromise that needs intervention. After stabilizing oxygenation, the nurse should address the low blood pressure to prevent shock.

The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis.

Rationale:

The client has a progressively enlarging, reddened area on the left calf with increasing calf circumference (40 cm → 42 cm in 24 hours), suggesting a developing deep vein thrombosis (DVT). A history of recent prolonged immobility (8-hour car trip) increases the risk of venous stasis, a major factor in DVT formation.

Low blood pressure (106/55 mm Hg) and elevated temperature (38°C/100.4°F) may indicate a systemic inflammatory response.

DVT can lead to pulmonary embolism (PE) if a clot dislodges and travels to the lungs.

Symptoms of PE include sudden dyspnea, chest pain, tachycardia, and hypoxia.

Early identification of DVT is crucial to prevent life-threatening PE.

Incorrect Options:

Lead poisoning → Home environment: No exposure to lead-based hazards is mentioned.

Pneumonia → Breath sounds: The client has clear breath sounds, ruling out pneumonia.

Atherosclerosis → Blood pressure: The client’s BP is not severely elevated, and no risk factors for atherosclerosis are noted.

Constipation → Diet: The client eats a high-fiber diet and drinks 2,000 mL of fluid daily, reducing constipation risk.

The client presents with chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort, which are classic signs of an acute MI.

ST-elevation on ECG and elevated troponin levels confirm myocardial infarction.

Actions to Take:

Administer Oxygen via nasal cannula 2 L/min: The client’s oxygen saturation is 88%, which is below the normal range. Supplemental oxygen helps improve myocardial oxygenation.

Request a prescription for aspirin 325 mg: Aspirin is a first-line treatment for MI as it prevents further platelet aggregation and reduces the risk of clot progression.

Parameters to Monitor:

Vital signs: Blood pressure, heart rate, and respiratory rate should be closely monitored to assess cardiovascular stability.

Electrocardiogram (ECG) rhythm: Continuous ECG monitoring is essential to detect arrhythmias, ischemic changes, or worsening ST elevation that may indicate ongoing myocardial injury.

Client has a BMI of 16 → A BMI of 16 indicates malnutrition, which weakens the immune system and impairs wound healing, making the client more prone to infections.

History of type 2 diabetes mellitus → Diabetes can impair white blood cell function and slow immune response, increasing infection risk.

Budesonide 6 mg PO daily → Budesonide is a corticosteroid, which suppresses the immune system and increases susceptibility to infections.

The client is exhibiting clinical manifestations of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE).

Rationale:

Deep Venous Thrombosis (DVT): Classic signs of DVT include throbbing pain, swelling, warmth, and discoloration in the right calf, which the client has had for three days.

Tenderness and pitting edema (1+) further support venous obstruction.

The client has an elevated D-dimer (1.0 mcg/mL, normal <0.4 mcg/mL), indicating a high likelihood of a thrombotic event. The client is taking a combined hormonal oral contraceptive (CHC), which increases the risk of venous thromboembolism.

Pulmonary Embolism (PE): The client reports shortness of breath for one day, a hallmark symptom of PE. DVT can dislodge and travel to the lungs, causing PE. Although lung sounds are clear and SpO₂ is 94%, PE can present without significant lung abnormalities in early stages.

Incorrect Options:

Peripheral Arterial Disease (PAD) → PAD presents with cool, pale skin, weak pulses, and intermittent claudication, which are not seen here.

Cellulitis → While cellulitis can cause redness and swelling, it is typically associated with fever, warmth, and skin infection, which the client does not have.

Popliteal Venous Aneurysm → This is rare and usually asymptomatic unless a clot forms. The client’s symptoms are more consistent with DVT.

Vasculitis → This involves inflammation of blood vessels, often with fever, rash, and systemic symptoms, which the client lacks.