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.

Answer and Explanation

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.

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Correct Answer is ["12.5"]

Explanation

To calculate the dosage of amoxicillin suspension to be administered every 8 hours, one must first determine the total daily dosage in milligrams. Since 1 gram equals 1000 milligrams, 1.5 grams is equivalent to 1500 milligrams. This total daily dosage needs to be divided into three doses, as it will be administered every 8 hours.

Therefore, each dose will be 1500 mg divided by 3, which equals 500 mg per dose. The medication bottle states that there are 200 mg of amoxicillin in every 5 mL of suspension. To find out how many mL correspond to a 500 mg dose, set up a proportion: 200 mg/5 mL = 500 mg/x mL. Solving for x gives x = (500 mg * 5 mL) / 200 mg, which equals 12.5 mL

Therefore, the nurse should administer 12.5 mL of the amoxicillin suspension every 8 hours.

A. Temperature B. Breath sounds C. Complete blood count D. Heart rate E. Peak inspiratory flow F. Serum sodium G. Peak expiratory flow H. Oxygen saturation

Correct Answer is ["A","B","D","G","H"]

Explanation

A. Assessing temperature is important to monitor for any signs of infection or inflammation, which could exacerbate the asthma condition or indicate a concurrent illness.
B. Evaluating breath sounds helps determine the effectiveness of the albuterol treatment in relieving bronchospasm. Clearer breath sounds suggest improved air entry and reduced wheezing.
C. While CBC can provide valuable information, it is not typically immediately necessary after an albuterol treatment unless there are specific concerns about infection or other systemic issues.
D. Monitoring the heart rate is crucial as albuterol can cause tachycardia (elevated heart rate) as a side effect. It's important to ensure that the heart rate does not become excessively elevated, which may indicate a need to adjust treatment or monitor more closely.
E. Peak inspiratory flow is less commonly used in asthma management compared to peak expiratory flow. It's the maximum flow rate during inhalation and is not typically assessed routinely in the immediate post-treatment period.
F. Assessing serum sodium is not directly related to monitoring asthma exacerbation or response to bronchodilator therapy.
G. PEF measures the maximum speed at which a person can exhale air after a deep breath. It is a direct indicator of lung function and the severity of airway obstruction in asthma. Assessing PEF post-albuterol treatment helps gauge how well the airways have responded to the bronchodilator therapy.
H. Checking oxygen saturation ensures that the patient's oxygen levels have improved following the administration of albuterol. The goal is to maintain oxygen saturation above 94%, as per the treatment plan.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["12.5"]

Explanation

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

Correct Answer is ["A","B","D","G","H"]

Explanation

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