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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?

A.

Increase IV fluid infusion per protocol.

B.

Lower the head of the clients bed in Trendelenburg position

C.

Document CVP and continue to monitor.

D.

Administer IV diuretic medications.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Blurred vision is not a typical symptom of left-sided heart failure.

B. Difficulty breathing while performing activities, such as climbing stairs, is a classic symptom of left-sided heart failure due to pulmonary congestion.

C. Increased water intake is not directly indicative of left-sided heart failure.

D. Nocturia can occur in heart failure, but it is less specific than dyspnea on exertion.

Correct Answer is C

Explanation

A. Using a feminine pad at night instead of a tampon can reduce the risk of TSS, which is correct.

B. Not using tampons reduces the risk of TSS. This statement is correct.

C. Tampons should be changed every 4 to 8 hours, not 10 hours, to reduce the risk of TSS. This statement indicates a lack of understanding.

D. Hand hygiene before inserting a tampon is critical for preventing TSS. This statement is correct.

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