A client with a history of heart failure presents with progressive shortness of breath over the last several days. Upon assessment, the nurse notes jugular venous distention, crackles in the lung bases auscultated bilaterally, and a bounding pulse. Which of the following interventions would be the nurse's priority?
Administration of IV antibiotics
Administration of IV diuretics
Isotonic intravenous fluids
Lay the client supine with legs elevated
The Correct Answer is B
A. Administration of IV antibiotics is not appropriate for this client, as there is no indication of an infection. The client's symptoms are consistent with fluid overload due to heart failure, not an infectious process.
B. Administration of IV diuretics is the priority intervention. The client is exhibiting signs of fluid overload, including jugular venous distention, crackles, and a bounding pulse. IV diuretics, such as furosemide, help reduce fluid volume, alleviate pulmonary congestion, and improve breathing.
C. Isotonic intravenous fluids would exacerbate the fluid overload and worsen the client's symptoms. This intervention is contraindicated in this scenario.
D. Laying the client supine with legs elevated is inappropriate for a client with heart failure and fluid overload, as it can increase venous return to the heart and worsen pulmonary congestion. Instead, the client should be positioned upright to improve breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encouraging the client to void every 5-6 hours is not appropriate for preventing complications in chronic pyelonephritis. Regular voiding every 2-3 hours is recommended to prevent urinary stasis and bacterial growth.
B. Limiting fluid intake to 1.5L/day is counterproductive in chronic pyelonephritis, as it increases the risk of concentrated urine and urinary tract infections.
C. While decreasing sodium intake may be beneficial in other conditions, it is not directly relevant to managing chronic pyelonephritis. The focus is on maintaining adequate hydration.
D. Increasing fluid intake to at least 3 L/day helps dilute the urine, reduce bacterial concentration, and flush out the urinary system, which is essential for managing and preventing further episodes of pyelonephritis.
Correct Answer is B
Explanation
A. DSW (Dextrose in water) is not specifically used for compatibility with antibiotics. It is an intravenous fluid that provides water and glucose, but its use is not based on antibiotic compatibility.
B. DSW (5% dextrose in water) provides free water to the body. In the case of acute dehydration and hypernatremia, the water helps to dilute the high sodium levels in the bloodstream, lowering the sodium concentration.
C. DSW does not contain higher-than-normal amounts of sodium. It contains only a small amount of sodium from the dextrose, and its primary role is to provide free water.
D. DSW is not used to pull water out of the interstitial space. Hypertonic solutions (like 3% saline) are used for that purpose, not DSW.
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