A client with severe heart failure develops elevated blood urea nitrogen (BUN) and creatinine levels. The nurse will plan care to meet the goal of

preventing hypertension

diluting nephrotoxic substances.

replacing fluid volume.

maintaining adequate cardiac output.

Answer and Explanation

The Correct Answer is D

A. preventing hypertension: While managing blood pressure is important in heart failure, the immediate concern with elevated BUN and creatinine is renal perfusion, not hypertension. Blood pressure control alone does not correct the underlying cause of kidney injury.

B. diluting nephrotoxic substances: Dilution may reduce risk from nephrotoxins, but in heart failure, fluid overload is a concern. This approach does not address the primary issue of reduced renal perfusion caused by low cardiac output.

C. replacing fluid volume: Fluid replacement in severe heart failure could worsen pulmonary edema and increase cardiac workload. The problem is not fluid deficit but inadequate perfusion to the kidneys due to poor cardiac output.

D. maintaining adequate cardiac output: Elevated BUN and creatinine in heart failure indicate reduced renal perfusion. Ensuring adequate cardiac output improves blood flow to the kidneys, supporting filtration and preventing further renal injury. This is the priority goal in care planning.

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Correct Answer is A

Explanation

A. Rapid pulse and prolonged capillary refill: A rapid pulse combined with delayed capillary refill strongly suggests poor perfusion and early hypovolemic shock. These findings indicate that the body is compensating for volume loss by increasing heart rate and redirecting blood to vital organs. Capillary refill slows as peripheral circulation decreases.

B. Increased BP with narrowed pulse pressure: Increased blood pressure does not align with internal bleeding, as hypovolemia typically causes the pressure to fall rather than rise. Narrowed pulse pressure can occur in shock, but pairing it with elevated BP makes internal hemorrhage less likely.

C. Sudden diaphoresis: Diaphoresis can occur with pain, anxiety, fever, or sympathetic activation, making it nonspecific. While it may accompany early shock, it does not reliably indicate internal bleeding on its own. The absence of other hemodynamic changes limits its diagnostic value. More definitive perfusion changes would be expected in hemorrhage.

D. Increasing urinary output: Rising urine output generally reflects adequate renal perfusion and fluid status, which contradicts signs of internal hemorrhage. As bleeding progresses, urine output typically declines due to reduced circulating volume. An increase suggests stability rather than deterioration.

A. Loss of distal pulses B. Increased capillary refill C. Increased sensitivity to pain in the area D. Limited range of motion

Correct Answer is A

Explanation

A. Loss of distal pulses: Loss of pulses indicates vascular compromise from circumferential edema and rigid eschar, which can rapidly progress to ischemia. This finding signals the need for immediate escharotomy to relieve pressure and restore perfusion to the affected extremity.

B. Increased capillary ref: Prolonged capillary refill can suggest reduced circulation, but it appears earlier and is less definitive than the complete loss of palpable pulses. While concerning, it does not carry the same urgency or confirm the need for surgical decompression.

C. Increased sensitivity to pain in the area: Heightened pain sensitivity may occur as tissues swell, but pain alone does not indicate critical circulatory obstruction. The presence or absence of pain is not a reliable determinant for the need for escharotomy compared with pulse changes.

D. Limited range of motion: Decreased mobility is common with circumferential burns due to stiffness and swelling, but it does not reliably signal vascular compromise. Although it affects function, it is not an indication for emergent escharotomy in the absence of circulatory impairment.

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