A client is admitted for recurrent peripheral edema. On admission the patient is AAOX3, lungs are clear to auscultations. Heart rate is 88 bmp, regular rate and rhythm. Respiratory rate is 24 breaths per minute. Abdomen is soft non-tender non-distended, last BM was yesterday and was reported by the patient to be soft, normal brown color. Patient has +2 pitting edema of the bilateral hands and bilateral ankles and feet. Blood pressure is 150/82 mmHg. Pulse ox is 88% on 3 liters of oxygen by nasal cannula.
What findings in this assessment require follow-up?
Pulse ox of 88% on 3 1pm NC
Lungs are clear to auscultation
+ 2 pitting edema of the bilateral hands
+ 2 pitting edema of the ankles and feet
Blood pressure of 150/82
Respiratory rate is 24
Abdomen is soft, non-tender, non-distended
Client is alert and oriented x 3
Heart rate is 88 bpm
Correct Answer : A,C,D,E,F
A. Pulse ox of 88% on 3 1pm NC: An oxygen saturation of 88% while receiving 3 liters of oxygen indicates significant impairment in gas exchange. This value is below the standard therapeutic target and suggests worsening pulmonary involvement or ventilation-perfusion mismatch. This finding requires immediate medical evaluation and potential adjustment of respiratory support.
B. Lungs are clear to auscultation: This is a normal finding indicating that, at the time of assessment, there is no audible fluid in the alveoli. While heart failure often causes crackles, clear lungs do not require immediate follow-up as an abnormal finding. It serves as a baseline for monitoring future respiratory changes.
C. + 2 pitting edema of the bilateral hands: Edema in the upper extremities is an atypical finding for standard dependent edema and suggests severe systemic fluid retention. It indicates that the venous backup has progressed beyond the lower extremities to involve more superior vascular beds. This requires investigation into the underlying cause of generalized anasarca.
D. + 2 pitting edema of the ankles and feet: Pitting edema in the lower extremities is a clinical manifestation of systemic venous congestion and fluid volume excess. This finding indicates that the current treatment for peripheral edema is not yet effective. The nurse must monitor this to evaluate the patient's response to diuretic therapy.
E. Blood pressure of 150/82: This reading indicates Stage 2 hypertension, which contributes to increased afterload and exacerbates heart failure. Elevated systemic vascular resistance places additional strain on the myocardium and impairs efficient pumping. Persistent hypertension requires pharmacological management to prevent further cardiac remodeling and damage.
F. Respiratory rate is 24: A rate of 24 breaths per minute is tachypneic and suggests the patient is compensating for hypoxia or decreased lung compliance. This increased work of breathing often precedes more severe respiratory distress in fluid-overloaded patients. It correlates with the low pulse oximetry and necessitates closer clinical observation.
G. Abdomen is soft, non-tender, non-distended: This is a normal physical assessment finding indicating the absence of ascites or organomegaly at this time. It suggests that the fluid volume excess has not yet resulted in significant peritoneal accumulation. No acute nursing or medical follow-up is required for this specific result.
H. Client is alert and oriented x 3: Normal mentation indicates that cerebral perfusion is currently adequate despite the patient's low oxygen saturation. It is a positive sign that the patient is not yet experiencing hypercapnia or severe hypoxia-induced encephalopathy. This baseline is used to monitor for any future neurological decline.
I. Heart rate is 88 bpm: A heart rate of 88 is within the normal adult range of 60 to 100 beats per minute. This indicates that the heart is not currently in a state of compensatory tachycardia to maintain cardiac output. It is a stable finding that does not require immediate clinical follow-up.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Bronchospasm: Non-selective beta-blockers inhibit beta-2 receptors located in the bronchial smooth muscle, leading to unintended constriction of the airways. This physiological response significantly increases airway resistance and can trigger acute respiratory distress in patients with underlying asthma or COPD. Clinicians must exercise extreme caution when prescribing these agents to individuals with reactive airway diseases.
B. Bradycardia: Beta-adrenoceptor antagonists decrease the firing rate of the sinoatrial node and slow conduction through the atrioventricular node. This negative chronotropic effect results in a reduced heart rate, which is a primary pharmacological action of the drug class. Excessive blockade can lead to symptomatic bradycardia, requiring a dose adjustment or discontinuation to maintain adequate cardiac output.
C. Hyperglycemia: Beta-blockers do not typically cause an elevation in blood glucose levels as a primary adverse effect. Instead, they are known to mask the sympathetic symptoms of hypoglycemia, such as tachycardia and tremors, which can be dangerous for diabetic patients. They may also slightly impair insulin release, but they are not categorized as hyper-glycemic agents.
D. Fatigue: The reduction in cardiac output and the blockade of peripheral beta-receptors often lead to a profound sense of lethargy or exercise intolerance. Patients frequently report feeling tired because the heart cannot increase its rate sufficiently to meet increased metabolic demands during physical activity. This is one of the most common reasons for patient non-compliance with beta-blocker therapy.
Correct Answer is B
Explanation
A. Irregular heart beat with a rate of 86 bpm: While a rate of 86 is within the normal range, the persistence of an irregular rhythm indicates that the client has not returned to normal sinus rhythm. The primary goal of therapy includes rhythm stabilization or better rate control. An irregular rhythm still suggests a deviation from the previous day's successful conversion.
B. No edema noted in the bilateral extremities: The resolution of peripheral edema is a direct indicator that diuretic therapy and heart failure management have been effective. It demonstrates that the excess fluid has been successfully mobilized and excreted from the body. This finding confirms an improvement in the client's congestive state.
C. hypoactive bowel sounds in all 4 quadrants: Hypoactive bowel sounds were present at the start of the assessment and their persistence does not indicate a successful cardiovascular intervention. This finding is likely unrelated to the primary cardiac issue or may be a side effect of other medications. Improvement in cardiac output usually improves systemic perfusion, including the gut.
D. Decreased urine output: Successful treatment with a diuretic like furosemide should result in increased, not decreased, urine output. A decrease in output would suggest worsening renal perfusion or a lack of response to the medication. Effective management of heart failure aims to reduce fluid volume through diuresis.
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