A nurse is caring for a 74-year-old female client who reports experiencing increased shortness of breath.
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 []
- Worsening of congestive heart failure is suggested by symptoms including labored breathing, coarse crackles, jugular vein distention (JVD), cool/clammy skin, and low oxygen saturation. These findings indicate pulmonary congestion due to fluid overload.
- Applying O₂ at 6L/min helps improve oxygenation and alleviate respiratory distress. Lower-flow oxygen (such as 2L/min) may not be sufficient in acute heart failure exacerbation.
- Monitoring respiratory rate is essential to track breathing effort and response to treatment.
- Monitoring oxygen saturation helps assess oxygenation status and effectiveness of interventions.
- Smoking cessation is important for long-term lung and cardiovascular health but does not address the acute issue.
- WBC count and temperature are more relevant to infections like pneumonia rather than acute heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Osler Nodes – These are tender, painful nodules on the fingers and toes, a classic sign of infective endocarditis.
B. Splinter Hemorrhages – Tiny blood clots under the fingernails occur due to microembolization from infected heart valves.
C. Petechial Hemorrhaging – Small red or purple spots on the skin or mucous membranes occur due to embolization of infected material.
D. Janeway Lesions – Painless, flat, red spots on the palms and soles caused by microemboli.
E. Fever with Chills – A common systemic symptom due to infection and inflammation.
Correct Answer is A
Explanation
A. IV Nitroglycerine is a vasodilator that improves coronary blood flow, reduces myocardial oxygen demand, and relieves chest pain in AMI.
B. IV Heparin is an anticoagulant that prevents further clot formation but does not dilate blood vessels.
C. Metoprolol, a beta-blocker, reduces heart rate and myocardial oxygen demand but does not cause coronary vasodilation.
D. Alteplase (fibrinolytic) helps dissolve clots in acute STEMI but does not directly dilate coronary arteries.
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