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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?

A.

Administration of IV antibiotics

B.

Administration of IV diuretics

C.

Isotonic intravenous fluids

D.

Lay the client supine with legs elevated

Answer and Explanation

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.
 


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Related Questions

Correct Answer is ["44"]

Explanation

Calculate the flow rate in mL/hour: 400 mL / 3 hours = 133.33 mL/hour (approximately)

Convert the flow rate to mL/minute: 133.33 mL/hour / 60 minutes/hour = 2.22 mL/minute (approximately)

Calculate the drops per minute: 2.22 mL/minute 20 gtt/mL = 44.4 gtt/minute

Round to the nearest whole number: 44 gtt/minute

Correct Answer is B

Explanation

A. Furosemide (Lasix) is a loop diuretic that typically causes the loss of potassium through the urine, thus putting clients at risk for hypokalemia, not hyperkalemia.
B. Spironolactone (Aldactone) is a potassium-sparing diuretic, meaning it helps the body retain potassium. As a result, it can lead to hyperkalemia, especially in patients with kidney dysfunction or when used with other medications that increase potassium levels.
C. Sodium polystyrene sulfate (Kayexalate) is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, thus lowering potassium levels. It does not contribute to hyperkalemia.
D. Insulin does not directly cause hyperkalemia; in fact, insulin administration can lower potassium levels by driving potassium into cells.

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