A nurse is caring for a client who has heart failure.
Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Fluid volume deficit
The client is receiving Furosemide (a diuretic) at a significant dose (80 mg IV three times per day). This medication promotes diuresis to reduce fluid overload in heart failure. The client's weight decreased from 97.5 kg on admission to 90.7 kg on Day 2, indicating a fluid loss of approximately 6.8 kg (about 15 pounds). This substantial weight loss suggests a risk for fluid volume deficit, which can lead to hypovolemia and potential complications such as hypotension and decreased tissue perfusion.
Acute kidney injury (AKI)
The client's BUN level increased from 10 mg/dL on admission to 20 mg/dL on Day 2, which suggests impaired kidney function. This change may indicate a decrease in glomerular filtration rate due to decreased renal perfusion secondary to fluid loss from diuresis. AKI is a known complication in heart failure patients receiving diuretic therapy, especially if there is inadequate monitoring and adjustment of diuretic doses.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Clients with this score may have altered consciousness and require close monitoring for changes in neurological status, respiratory function, and other complications. Placing this client closest to the nurses' station allows for prompt assessment and intervention if there is deterioration or emergent need.
A Clients with a score of 0 are generally stable and may not require immediate or intensive monitoring. Therefore, this client may not need to be placed closest to the nurses' station unless there are other medical considerations.
B. A grade 1 concussion is considered mild, and while the client may have symptoms such as headache, they are typically stable with minimal risk of deterioration. Monitoring for worsening symptoms is important, but this client may not require immediate proximity to the nurses' station unless symptoms worsen unexpectedly.
D. Clients who are brain dead and awaiting organ procurement are typically stable in terms of neurological status as they are no longer responsive. This client may not necessarily need to be closest to the nurses' station unless specific care needs arise.
Correct Answer is B
Explanation
B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.
A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.
C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.
D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.
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