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A nurse is caring for a client who has heart failure.

Nurses' Notes.

Day 1: Vital Signs.

Bilateral breath sounds clear and present throughout.

Weight 80 kg (176 lb). Urine output 480 mL/8 hr. Day 4: Breath sounds scattered, crackles heard bilaterally.

Apical heart rate rapid and irregular.

Audible S3 gallop.

Weight 82.1 kg (181 lb). Urine output 320 mL/8 hr. Vital Signs.

Day 1: Temperature 37.6° C (99.7° F). Blood pressure 108/50 mm Hg. Pulse 98/min.

Respiratory rate 20/min.

Pulse oximetry 95% on room air.

Day 4: Temperature 36.8° C (98.2° F). Blood pressure 138/80 mm Hg. Pulse 112/min.

Respiratory rate 28/min.

Pulse oximetry 88% on room air.

A nurse is reviewing the assessment findings for the client on day 4. Which of the following findings requires further action? (Select all that apply.).

Temperature.

Oxygen saturation.

Blood pressure.

Weight.

Urine output.

Breath sounds.

Answer and Explanation

Correct Answer : B,C,D,F

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

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Correct Answer is B

Explanation

Choice A rationale:

A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.

Choice B rationale:

Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.

Choice C rationale:

A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.

Choice D rationale:

An increase in blood pressure is not typically a reason to stop thrombolytic therapy.

So, the correct answer is B, after analyzing all choices.

A. Weight increase from 120 pounds to 122 pounds over 3 days. B. Serum potassium level 3.0 mEq/L after 1 week of therapy. C. Palpable liver edge 2 cm below the ribs on the right side. D. Presence of 1+ to 2+ edema in the feet and ankles.

Correct Answer is B

Explanation

Choice A rationale:

A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.

Choice B rationale:

A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.

Choice C rationale:

A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.

Choice D rationale:

The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.

So, the correct answer is Choice B, after analyzing all choices.

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The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

Correct Answer is B

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Correct Answer is B

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