A nurse in the emergency department is caring for a client.
Exhibit 1
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Condition most likely experiencing:
The client exhibits classic symptoms of left-sided heart failure, including dyspnea, nocturia, crackles, a dry hacking cough (worse at night), S3 gallop, and fatigue.
Low blood pressure (98/50 mm Hg), tachycardia (112/min), tachypnea (28/min), and oxygen saturation of 88% indicate poor cardiac output and pulmonary congestion.
Elevated BNP (410 pg/mL; normal <100 pg/mL) confirms heart failure.
The atrial fibrillation on ECG is a common complication of heart failure, further worsening cardiac function.
Actions to take:
Administer supplemental oxygen: The client’s SpO2 is 88%, indicating hypoxia. Oxygen therapy will improve oxygenation and reduce respiratory distress.
Elevate the head of the client’s bed: This helps reduce pulmonary congestion and improve breathing by promoting lung expansion.:
Parameters to monitor:
Weight: Daily weights are the best indicator of fluid retention and effectiveness of diuretic therapy. Sudden weight gain suggests worsening heart failure.
Urine output: Low urine output may indicate worsening heart failure and poor renal perfusion. Increased urine output after treatment suggests effective fluid removal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The client is at risk for developing pulmonary embolism due to possible deep vein thrombosis.
Rationale:
The client has a progressively enlarging, reddened area on the left calf with increasing calf circumference (40 cm → 42 cm in 24 hours), suggesting a developing deep vein thrombosis (DVT). A history of recent prolonged immobility (8-hour car trip) increases the risk of venous stasis, a major factor in DVT formation.
Low blood pressure (106/55 mm Hg) and elevated temperature (38°C/100.4°F) may indicate a systemic inflammatory response.
DVT can lead to pulmonary embolism (PE) if a clot dislodges and travels to the lungs.
Symptoms of PE include sudden dyspnea, chest pain, tachycardia, and hypoxia.
Early identification of DVT is crucial to prevent life-threatening PE.
Incorrect Options:
Lead poisoning → Home environment: No exposure to lead-based hazards is mentioned.
Pneumonia → Breath sounds: The client has clear breath sounds, ruling out pneumonia.
Atherosclerosis → Blood pressure: The client’s BP is not severely elevated, and no risk factors for atherosclerosis are noted.
Constipation → Diet: The client eats a high-fiber diet and drinks 2,000 mL of fluid daily, reducing constipation risk.
Correct Answer is []
Explanation
The client presents with chest pain radiating to the left arm, sweating, shortness of breath, and epigastric discomfort, which are classic signs of an acute MI.
ST-elevation on ECG and elevated troponin levels confirm myocardial infarction.
Actions to Take:
Administer Oxygen via nasal cannula 2 L/min: The client’s oxygen saturation is 88%, which is below the normal range. Supplemental oxygen helps improve myocardial oxygenation.
Request a prescription for aspirin 325 mg: Aspirin is a first-line treatment for MI as it prevents further platelet aggregation and reduces the risk of clot progression.
Parameters to Monitor:
Vital signs: Blood pressure, heart rate, and respiratory rate should be closely monitored to assess cardiovascular stability.
Electrocardiogram (ECG) rhythm: Continuous ECG monitoring is essential to detect arrhythmias, ischemic changes, or worsening ST elevation that may indicate ongoing myocardial injury.
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