A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

Check MAR for antianxiety medication

Ask when the dyspnea started

Notify the provider

Increase oxygen from 3L/minute to 5L/minute

Answer and Explanation

The Correct Answer is D

In this scenario, the client is exhibiting signs of severe respiratory distress, which could indicate worsening acute heart failure and potential respiratory failure.

a. Check MAR for antianxiety medication: While anxiety may exacerbate the client's symptoms, the priority at this moment is to address the acute respiratory distress and ensure adequate oxygenation. Checking the medication administration record (MAR) for antianxiety medication can be done later but is not the immediate priority.

b. Ask when the dyspnea started: While obtaining a thorough history is important for understanding the onset and progression of the client's symptoms, it is not the first action to take in this critical situation. The client's current condition requires immediate intervention to ensure adequate oxygenation and stabilization.

c. Notify the provider: Notifying the provider is important, especially in a situation where the client's condition is deteriorating rapidly. However, this action may take some time, and the priority is to address the client's immediate needs first.

d. Increase oxygen from 3L/minute to 5L/minute: This is the most appropriate action to take first. The client is showing signs of severe respiratory distress with cyanosis and increased work of breathing. Increasing the oxygen flow rate from 3L/minute to 5L/minute can help improve oxygenation and alleviate hypoxemia, which is crucial in the management of acute heart failure exacerbation.

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Correct Answer is D

Explanation

a. Dopamine: Dopamine is a medication that primarily acts as a vasopressor and inotropic agent. While it can increase cardiac contractility and improve cardiac output, it does not directly decrease afterload. In fact, dopamine may increase systemic vascular resistance (afterload) at higher doses.

b. Warfarin: Warfarin is an anticoagulant medication used to prevent blood clot formation, particularly in individuals with certain cardiac conditions such as atrial fibrillation or mechanical heart valves. While warfarin is important for preventing thromboembolic events in individuals with mitral valve regurgitation, it does not directly affect afterload.

c. Digoxin: Digoxin is a medication that primarily acts as a positive inotropic agent by increasing myocardial contractility. While it can improve cardiac function, particularly in individuals with heart failure, it does not directly decrease afterload.

d. Lisinopril: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor medication that reduces blood pressure by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. By reducing angiotensin II levels, lisinopril dilates blood vessels and decreases systemic vascular resistance (afterload), thus reducing the workload on the heart. Therefore, lisinopril is the medication that would help decrease afterload for a client with mitral valve regurgitation.

A. Check current WBC count B. Assess for hypertension C. Auscultate heart sounds D. Measure blood glucose

Correct Answer is C

Explanation

a. Check current WBC count: While an elevated white blood cell (WBC) count may indicate inflammation, it is not specific to the assessment of cardiac tamponade. WBC count may be elevated in pericarditis due to the inflammatory process, but it does not directly assess for the potential complication of cardiac tamponade.

b. Assess for hypertension: Hypertension is not typically associated with cardiac tamponade. Instead, cardiac tamponade is characterized by hemodynamic compromise, which may manifest as hypotension rather than hypertension. While assessing blood pressure is important in overall cardiovascular assessment, it is not specific to detecting cardiac tamponade.

c. Auscultate heart sounds: Auscultating heart sounds, specifically for the presence of muffled heart sounds (reduced intensity of heart sounds) and distant heart sounds, is a key assessment for detecting cardiac tamponade, a potential complication of pericarditis. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. This can lead to hemodynamic compromise and potentially life-threatening consequences. Muffled or distant heart sounds are classic signs of cardiac tamponade and indicate the need for immediate intervention.

d. Measure blood glucose: Blood glucose measurement is not directly related to the assessment of cardiac tamponade. While monitoring blood glucose levels may be important in clients with diabetes or those at risk of hyperglycemia, it does not provide information specific to the detection of cardiac tamponade.

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A client with acute heart failure is sitting up in bed with respiratory rate of 28, cyanosis and is using accessory muscles. Unable to speak due to the dyspnea. She nods her head ‘yes’ when asked if she is short of breath. What action should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a client diagnosed with mitral valve regurgitation. Which medication would help decrease afterload for this client?

Correct Answer is D

Explanation

The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

Correct Answer is C

Explanation

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