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
Explanation
A. Defibrillation is the priority intervention for pulseless ventricular tachycardia, as it can restore a normal rhythm. It should be performed as soon as possible.
B. Synchronized cardioversion is used for hemodynamically unstable tachyarrhythmias with a pulse, not for pulseless V-Tach.
C. CPR should be initiated if a defibrillator is not immediately available, but defibrillation is the definitive treatment.
D. Repeating an ECG does not address the immediate life-threatening situation.
Correct Answer is A
Explanation
A. A murmur is the expected heart sound in mitral valve regurgitation, caused by the backflow of blood into the left atrium during systole. It is typically a holosystolic murmur heard best at the apex of the heart.
B. S3 and S4 heart sounds may be heard in heart failure but are not specific for mitral regurgitation.
C. A friction rub is associated with pericarditis, not valvular disease.
D. A click is typically heard in mitral valve prolapse, not mitral regurgitation.
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