A client with heart failure reports dyspnea and anxiety. Upon examination the client is tachycardic and has crackles throughout bilateral lung fields. Which actions will the nurse take now? Select all that apply.

Monitor urine output

Assess pulse oximetry

Check PT/INR

Infuse 0.9% NS with 20 mEq KCl at 50 ml/hr

Administer 40 mg furosemide IV now

Answer and Explanation

Correct Answer : A,B,E

a. Monitor urine output: Monitoring urine output is important in clients with heart failure to assess renal perfusion and renal function. Decreased urine output may indicate worsening heart failure or inadequate response to treatment. Therefore, monitoring urine output is appropriate in this situation to assess the client's fluid status and response to therapy.

b. Assess pulse oximetry: Assessing pulse oximetry is essential to evaluate the client's oxygen saturation levels, especially in a client presenting with dyspnea and crackles throughout bilateral lung fields. Decreased oxygen saturation may indicate respiratory compromise or worsening heart failure. Therefore, assessing pulse oximetry is necessary to monitor the client's respiratory status and guide interventions.

c. Check PT/INR: Checking PT/INR (Prothrombin Time/International Normalized Ratio) is not indicated in this situation. PT/INR monitoring is typically performed in clients on anticoagulant therapy such as warfarin to assess coagulation status and therapeutic levels. It is not directly relevant to the client's current presentation of dyspnea, tachycardia, and crackles.

d. Infuse 0.9% NS with 20 mEq KCl at 50 ml/hr: Infusing normal saline (0.9% NS) with potassium chloride (KCl) is not appropriate based solely on the client's presentation of dyspnea, anxiety, tachycardia, and crackles. While fluid and electrolyte balance are important considerations in heart failure management, administering IV fluids and electrolytes should be guided by the client's fluid status, electrolyte levels, and response to treatment.

e. Administer 40 mg furosemide IV now: Administering furosemide IV (intravenous loop diuretic) is appropriate in this situation to manage the client's symptoms of dyspnea and crackles indicative of fluid overload in heart failure. Furosemide helps promote diuresis and reduce fluid volume, thereby alleviating symptoms of congestion and improving respiratory distress.

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Correct Answer is D

Explanation

a. “The left side of your heart is having trouble overcoming the resistance in the blood vessels of your body.”

This explanation is not specific to mitral stenosis. It describes systemic vascular resistance, which is a broader concept related to hypertension and vascular health. Mitral stenosis specifically involves narrowing of the mitral valve, which affects blood flow between the left atrium and left ventricle.

b. “When your heart beats, some of the blood that should leave the left ventricle is backing up through a leaking valve.”

This explanation is more accurate for mitral regurgitation rather than mitral stenosis. Mitral regurgitation involves the leaking of blood backward through the mitral valve into the left atrium during ventricular systole. Mitral stenosis, on the other hand, involves narrowing or constriction of the mitral valve, which impedes the flow of blood from the left atrium to the left ventricle during diastole.

c. “The valve between your heart and lungs has become inelastic.”

This explanation is not entirely accurate. While mitral stenosis does involve changes in the mitral valve structure, such as thickening and calcification, the term "inelastic" does not fully describe the pathology of mitral stenosis. Mitral stenosis is characterized by the narrowing (stenosis) of the mitral valve orifice, which restricts blood flow from the left atrium to the left ventricle.

d. “The mitral valve has become stiff and narrowed which slows the blood between the two chambers.”

This explanation is the most accurate description of mitral stenosis. It correctly identifies the problem as the narrowing and stiffening (stenosis) of the mitral valve, which impedes the flow of blood from the left atrium to the left ventricle during diastole. This explanation helps the client understand how the condition affects the function of the mitral valve and the flow of blood within the heart.

A. Kussmaul respirations B. Muscle spasms C. Paresthesia in fingers D. Tinnitus

Correct Answer is A

Explanation

a. Kussmaul respirations: Metabolic acidosis leads to an accumulation of acids in the body, resulting in compensatory hyperventilation to try to decrease the levels of carbon dioxide and increase pH. Kussmaul respirations are deep, rapid, and labored breathing patterns characteristic of this compensation mechanism.

b. Muscle spasms: While muscle spasms can occur in various conditions, they are not specific to metabolic acidosis. Other factors, such as electrolyte imbalances or dehydration, may cause muscle spasms.

c. Paresthesia in fingers: Paresthesia (tingling or numbness) in the fingers can occur due to metabolic acidosis. Acidosis affects nerve function, leading to abnormal sensations in the extremities. It is not specific to metabolic acidosis.

d. Tinnitus: Tinnitus is not typically associated with metabolic acidosis. It is more commonly associated with conditions such as ototoxicity, Meniere's disease, or vascular disorders affecting the inner ear.

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A client with heart failure reports dyspnea and anxiety. Upon examination the client is tachycardic and has crackles throughout bilateral lung fields. Which actions will the nurse take now? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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