A client with heart failure (HF) is receiving IV fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider (HCP)?

Inspect for distention of peripheral veins.

Assess for inflammation of the calves.

Observe for changes in breathing pattern.

Palpate the volume of pedal pulses.

Answer and Explanation

The Correct Answer is C

Choice A reason: Peripheral vein distention may support the presence of fluid overload, but it is not as critical as assessing respiratory compromise, which can signal pulmonary edema or worsening heart failure.

Choice B reason: Inflammation of the calves may indicate deep vein thrombosis (DVT), which is a separate concern. It does not directly relate to fluid overload or heart failure exacerbation.

Choice C reason: Changes in breathing pattern—such as increased respiratory rate, dyspnea, or use of accessory muscles—are key indicators of pulmonary congestion and worsening heart failure. This assessment provides vital information for clinical decision-making.

Choice D reason: Palpating pedal pulses helps assess peripheral perfusion but does not provide insight into fluid status or respiratory compromise. It is less urgent in the context of suspected fluid overload.

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Correct Answer is D

Explanation

Choice A reason: Requesting acetaminophen is part of the recommendation phase of SBAR, not the initial step.
Choice B reason: Explaining urgency is important but comes after identifying the client and situation.
Choice C reason: Pretransfusion temperatures are part of the assessment phase and should follow the initial identification.
Choice D reason: SBAR begins with the “Situation,” which includes stating the client’s name and admitting diagnosis to establish context and ensure accurate communication.

Correct Answer is D

Explanation

Choice A reason: Requesting acetaminophen is part of the recommendation phase of SBAR and should come after the situation and assessment have been communicated.
Choice B reason: Explaining urgency is important but follows the initial identification of the client and situation.
Choice C reason: Pretransfusion temperatures are part of the assessment phase and should be communicated after the situation and background.
Choice D reason: SBAR begins with the “Situation,” which includes stating the client’s name and admitting diagnosis. This establishes context and ensures the provider understands who the report concerns.

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A client with heart failure (HF) is receiving IV fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider (HCP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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