A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

Administer diuretic medication as prescribed.

Elevate the client’s legs to reduce swelling.

Assess the client’s respiratory status and oxygen saturation.

Restrict fluid intake to prevent fluid overload.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.

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Correct Answer is A

Explanation

Choice A rationale
Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.
Choice B rationale
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.
Choice C rationale
Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.
Choice D rationale
Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.

A. Maintain the client in a supine position. B. Maintain a high-Fowler’s position when the client is in bed. C. Elevate the stump on a pillow. D. Position the client on the abdomen for 20 to 30 minutes twice a day.

Correct Answer is D

Explanation

Choice D rationale

Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.

Choice A rationale

Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.

Choice B rationale

Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.

Choice C rationale

Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.

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A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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