A client with heart failure is receiving intravenous 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?

Observe for change in breathing pattern.

Palpate the volume of pedal pulses.

Assess for inflammation of the calves.

Inspect for distention of peripheral veins.

Answer and Explanation

The Correct Answer is A

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

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Correct Answer is C

Explanation

Choice A reason: Measuring abdominal girth monitors distention but is less critical before digital removal of a fecal impaction. Impaction causes constipation, but girth changes are slow. Vital signs detect autonomic responses like bradycardia from vagal stimulation during the procedure, making them more urgent to ensure safety.

Choice B reason: Bowel sounds indicate motility, reduced in impaction, but do not predict complications during digital removal, which risks vagal stimulation causing bradycardia. Vital signs are critical, detecting cardiovascular instability, ensuring safety during this invasive procedure, making bowel sounds less immediate for assessment.

Choice C reason: Assessing vital signs is essential, as digital removal stimulates rectal nerves, potentially triggering a vagal response, causing bradycardia or hypotension. This risks syncope or shock. Monitoring heart rate and blood pressure ensures cardiovascular stability, preventing complications during this procedure, addressing autonomic risks effectively.

Choice D reason: Breath sounds assess respiratory status, unrelated to fecal impaction removal, a gastrointestinal issue. The procedure risks vagal stimulation, not pulmonary effects. Vital signs detect cardiovascular changes like bradycardia, ensuring safety during rectal manipulation, making breath sounds irrelevant for this assessment.

A. Baked potato with skin. B. Orange juice. C. White rice. D. Banana smoothie.

Correct Answer is C

Explanation

Choice A reason: Baked potato with skin is high in potassium (about 900 mg), unsuitable for CKD, where impaired renal excretion risks hyperkalemia, causing cardiac arrhythmias. White rice is low-potassium, aligning with dietary restrictions, demonstrating understanding of the need to limit potassium intake in renal disease.

Choice B reason: Orange juice contains high potassium (about 500 mg per cup), dangerous in CKD, as reduced glomerular filtration increases hyperkalemia risk, affecting cardiac conduction. White rice, with minimal potassium, complies with restrictions, indicating the client’s understanding of safe dietary choices for kidney function.

Choice C reason: White rice is low in potassium (about 50 mg per cup), appropriate for CKD, where the kidneys cannot excrete excess potassium, risking hyperkalemia and arrhythmias. Choosing white rice shows the client understands the low-potassium diet, supporting safe management of renal disease and electrolyte balance.

Choice D reason: Banana smoothie is high in potassium (about 400 mg per banana), contraindicated in CKD, where hyperkalemia risks cardiac instability due to poor renal clearance. White rice, low in potassium, reflects dietary compliance, demonstrating the client’s understanding of restrictions to prevent electrolyte imbalances.

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A client with heart failure is receiving intravenous 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?

Nursing Test Bank

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