A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?
Volume of pedal pulses.
Length of capillary refill.
Rhythm of apical pulse.
Degree of skin elasticity.
The Correct Answer is C
Rationale
A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.
B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.
C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.
D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.
For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).
This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.
Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.
Correct Answer is B
Explanation
Rationale
A. Respiratory rate is important because opioid-induced respiratory depression is a significant concern with hydromorphone. Assessing the respiratory rate helps the nurse detect early signs of respiratory depression.
B. Pain scale is essential to evaluate the effectiveness of the equianalgesic dose. The nurse should ensure that the pain is adequately controlled with the IV dose comparable to what was achieved with the PO dose.
C. Blood pressure is monitored to detect any potential hypotensive effects of hydromorphone, particularly with IV administration.
D. Level of consciousness is assessed to ensure that the client is not overly sedated or experiencing other neurological side effects of the medication.
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