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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 C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

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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