A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

Use non-steroidal anti-inflammatory drugs for discomfort.

Limit sodium in the diet to 3.5 g/day.

Place client in a lateral position.

Limit fluid intake to 2 liters/day.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Using non-steroidal anti-inflammatory drugs (NSAIDs) for discomfort is not recommended for patients with heart failure because NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also interfere with the effects of certain heart failure medications.

Choice B reason:

Limiting sodium in the diet to 3.5 g/day is not restrictive enough for heart failure patients. Typically, heart failure management involves reducing sodium intake to around 2-2.3 g/day to help prevent fluid retention and reduce the workload on the heart.

Choice C reason:

Placing the client in a lateral position is not specifically beneficial in the management of heart failure. While changing positions can be part of general patient care, it does not directly address the fluid balance or cardiac workload in heart failure patients.

Choice D reason:

Limiting fluid intake to 2 liters/day is a common intervention for managing heart failure. This helps to prevent fluid overload, which can exacerbate heart failure symptoms and lead to complications such as pulmonary edema. Maintaining a careful balance of fluid intake is essential for managing heart failure effectively.

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Correct Answer is A

Explanation

Choice A reason:

Hypoxia not responsive to oxygen therapy is a hallmark early sign of ARDS. ARDS is characterized by acute onset of hypoxemia that does not improve with supplemental oxygen. This refractory hypoxemia is due to severe inflammation and increased permeability of the alveolar-capillary barrier, leading to pulmonary edema and impaired gas exchange.

Choice B reason:

Elevated lactate levels can indicate tissue hypoxia and metabolic stress, which are concerning findings in critically ill patients. However, elevated lactate is not specific to ARDS and can be seen in various conditions, including sepsis and shock. It is not the primary early indicator of ARDS.

Choice C reason:

Metabolic alkalosis is not typically associated with ARDS. ARDS usually involves respiratory failure, which may lead to respiratory acidosis. Metabolic alkalosis can occur in other conditions, such as excessive loss of gastric acid or diuretic use, but it is not an early sign of ARDS.

Choice D reason:

Severe, unexplained electrolyte imbalance can occur in critically ill patients but is not specific to ARDS. Electrolyte imbalances can result from various factors, including fluid shifts, renal dysfunction, and medication effects. These imbalances do not serve as an early diagnostic indicator of ARDS.

A. Palpate the bladder for distention. B. Initiate oxygen via a nasal cannula. C. Place the patient in a supine position. D. Administer a prescribed beta-blocker.

Correct Answer is A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

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