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 B
Explanation
A. The patient should increase fluid intake to 6 to 8 glasses of water daily, not 1 to 2 glasses, to help flush bacteria out of the urinary tract.
B. Phenazopyridine (Pyridium) can cause orange or red discoloration of urine, which is a harmless and temporary side effect that resolves after the medication is stopped. This indicates the patient understands the teaching.
C. Stopping medications prematurely can lead to incomplete treatment of the infection and potential antibiotic resistance. Patients should complete the full course of prescribed antibiotics.
D. Sulfamethoxazole-trimethoprim (Bactrim) is an antibacterial, and phenazopyridine is a urinary analgesic; neither medication is used to treat fungal infections.
Correct Answer is D
Explanation
A. Ensuring an incentive spirometer is available is important for postoperative care to prevent atelectasis, but it is not the priority immediately before surgery.
B. Preoperative teaching is valuable but should ideally be completed earlier in the care process. Last-minute teaching may overwhelm the patient or delay critical interventions.
C. Reporting allergies is essential, but if the allergy to sardines does not pertain to the current surgical plan or medications, it is not the immediate priority in this situation.
D. Administering the preoperative intravenous antibiotic is the top priority because it helps reduce the risk of surgical site infections. Timing of preoperative antibiotics is critical to their effectiveness.
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