A nurse is admitting a client to the medical-surgical unit.
Based on the nurse's assessment findings, click to highlight the specific interventions and orders the nurse would expect to implement for this client.
- Administer furosemide 40 mg via IV push once.
- Begin an IV infusion of normal saline (NS) at 150 mL/hr.
- Administer digoxin 0.25 mg via IV push NOW.
- Monitor daily weights.
- Call a code STEMI.
- Monitor strict intake and output.
- Prepare the client for an echocardiogram.
- Prepare the client for a radiofrequency catheter ablation.
Administer furosemide 40 mg via IV push once.
Begin an IV infusion of normal saline (NS) at 150 mL/hr.
Administer digoxin 0.25 mg via IV push NOW.
Monitor daily weights.
Call a code STEMI.
Monitor strict intake and output.
Prepare the client for an echocardiogram.
Prepare the client for a radiofrequency catheter ablation.
The Correct Answer is ["A","D","F","G"]
A. Administering furosemide 40 mg via IV push once is appropriate for treating fluid overload, as evidenced by pitting edema and crackles in the lungs, common in heart failure.
B. An IV infusion of normal saline (NS) at 150 mL/hr is not appropriate for this client as it can exacerbate fluid overload and worsen heart failure symptoms.
C. Administering digoxin 0.25 mg via IV push NOW may be indicated, but considering the client's low pulse rate (55/min), caution is necessary due to the risk of digoxin toxicity and bradycardia.
D. Monitoring daily weights is crucial for assessing fluid balance in heart failure patients and detecting any changes in fluid status.
E. Calling a code STEMI is not appropriate as the client does not exhibit signs of a STEMI; troponin levels are not elevated, and there is no indication of an acute myocardial infarction.
F. Monitoring strict intake and output helps in managing fluid balance and ensuring accurate assessment of the client's fluid status.
G. Preparing the client for an echocardiogram is appropriate to assess cardiac function and evaluate the severity of heart failure.
H. Radiofrequency catheter ablation is not indicated for this client as it is typically used to treat arrhythmias, not heart failure or fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jugular vein distention (JVD) is more commonly associated with right-sided heart failure, not left-sided heart failure.
B. Peripheral edema is also more commonly associated with right-sided heart failure.
C. Ascites or fluid accumulation in the abdomen is typically associated with right-sided heart failure.
D. Pink, frothy sputum is indicative of pulmonary edema, which is a common symptom of left-sided heart failure due to the backup of blood into the lungs.
Correct Answer is ["24"]
Explanation
To calculate the IV pump rate, you'll need to use the formula: (Ordered amount of medication (units/hr) × Volume of fluid in mL) / Amount of medication in the volume = IV pump rate in mL/hr. For the given scenario, the ordered amount is 1,200 units/hr, the volume of fluid is 500 mL, and the amount of medication in the volume is 25,000 units. Plugging these numbers into the formula gives you: (1,200 units/hr × 500 mL) / 25,000 units = 24 mL/hr. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.
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