A nurse is caring for a client admitted to the intensive care unit. Assessment findings are:
BP 160/90
HR 100
RR 27
Sp02 89%
Central Venous Pressure (CVP) 18 mmHg
Pulmonary Arterial Wedge Pressure (PAWP) 21 mmHg. Echocardiogram: Ejection Fraction 30%
BNP 1300 pg/mL
What is the nurse's priority action?
Increase IV fluid infusion per protocol.
Lower the head of the clients bed in Trendelenburg position
Document CVP and continue to monitor.
Administer IV diuretic medications.
The Correct Answer is D
A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.
B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.
C. Monitoring is important but does not address the immediate need to manage fluid overload.
D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Magnetic resonance imaging (MRI) may be used in some cases, but TRUS is more commonly used to guide biopsies after concerns arise from DRE or PSA findings.
B. Uroflowmetry studies measure urine flow, which is not the primary concern in evaluating an enlarged prostate related to potential cancer.
C. Cystourethroscopy is used to evaluate the bladder or urethra and is not typically needed in the assessment of an enlarged prostate.
D. Transrectal ultrasonography (TRUS) is commonly used in the evaluation of prostate abnormalities, especially when there are concerns about prostate cancer due to an abnormal DRE or elevated PSA. It helps in visualizing the prostate and guiding biopsy.
Correct Answer is ["937.5"]
Explanation
Calculate the fluid volume to be administered in the remaining 16 hours:
Total fluid volume - Fluid administered in the first 8 hours = Remaining fluid volume
30,000 mL - (1875 mL/hr * 8 hr) = 15,000 mL
Calculate the infusion rate for the remaining 16 hours:
Remaining fluid volume / Remaining time = Infusion rate
15,000 mL / 16 hr = 937.5 mL/hr
Therefore, the nurse should infuse the IV fluids at a rate of 937.5 mL/hr after the first 8 hours.
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