A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider’s office.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct condition
Heart failure is indicated by dyspnea, orthopnea, fatigue, peripheral edema, and elevated BNP >100 pg/mL (client's is 352 pg/mL).
Cardiomegaly and pleural congestion on chest x-ray further confirm fluid overload consistent with heart failure.
Atrial fibrillation, irregular pulse, and furosemide administration support cardiovascular compromise.
The use of accessory muscles and need for oxygen show decreased pulmonary function due to fluid buildup.
Absence of infection or anemia and normal glucose levels rule out other causes.

Rationale for correct actions
Elevating the head of the bed reduces venous return and pulmonary congestion, easing respiratory effort in heart failure.
It enhances diaphragmatic expansion, improving ventilation and oxygenation.
This non-invasive measure provides immediate symptom relief in fluid-overloaded patients.
Encouraging a low-sodium diet limits fluid retention by reducing intravascular volume through osmotic balance.
It helps decrease preload and afterload, improving cardiac efficiency.
Long-term dietary sodium restriction is essential to minimize exacerbation of fluid overload in chronic heart failure.

Rationale for correct parameters
Monitoring urinary output evaluates furosemide effectiveness and fluid status.
It reflects renal perfusion and response to diuretics in volume-overloaded states.
Oliguria may indicate worsening heart failure or renal dysfunction.
Blood pressure monitoring assesses hemodynamic stability and effectiveness of medications like carvedilol.
Hypertension increases afterload, exacerbating heart failure.
Hypotension may signal over-diuresis or digoxin toxicity.

Rationale for incorrect conditions
Anemia is unlikely due to normal hemoglobin (14.2 g/dL; normal 14–18 g/dL).
There is no evidence of blood loss, pallor, or tachycardia secondary to low oxygen-carrying capacity.
Type 2 diabetes is stable; HbA1c is 6.2% (target <7%) and glucose is normal at 102 mg/dL.
No symptoms of hypo/hyperglycemia are reported.
Urinary tract infection is excluded by normal WBC count (6,000/mm³), afebrile status, and clear urinalysis.

Rationale for incorrect actions
Teaching hyperglycemia signs is diabetes-specific, not acute heart failure management.
Iron-rich foods are unnecessary with normal hemoglobin and no anemia.
Foot sensation assessment pertains to diabetic neuropathy, not cardiopulmonary care.

Rationale for incorrect parameters
WBC count is normal and not relevant to non-infectious heart failure.
Fingerstick glucose is stable and not related to current symptoms.
Hemoglobin is within range and not a focus in fluid overload without anemia.

Take home points

Heart failure presents with fluid retention signs, elevated BNP, and pulmonary congestion.
Differentiate heart failure from anemia by evaluating hemoglobin and clinical signs.
Avoid focusing on diabetes in stable patients without hyper/hypoglycemic symptoms.
Management priorities in heart failure include fluid control, oxygenation, and dietary sodium restriction.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Cooking fish and meats well ensures the destruction of potential pathogens like bacteria (e.g., Salmonella, E. coli) and parasites that can cause severe infections in immunocompromised individuals. Thorough cooking denatures proteins and lipids essential for microbial survival and replication.

Choice B rationale

Maintaining good hygiene, including regular bathing and oral care, reduces the overall microbial load on the skin and mucous membranes. This minimizes the risk of opportunistic infections, as compromised immune systems are less capable of defending against common environmental microorganisms.

Choice C rationale

Sterilizing dishes before use is generally excessive for discharge instructions, as proper washing with hot water and soap is typically sufficient to remove most pathogens. Sterilization is usually reserved for medical equipment or highly sensitive environments.

Choice D rationale

Frequent hand washing mechanically removes transient and resident flora, including bacteria and viruses. This is a critical barrier against transmitting infections, particularly for immunocompromised individuals whose primary defense mechanisms are impaired, preventing ingestion of pathogens.

Choice E rationale

Avoiding consuming raw foods, such as sushi, uncooked eggs, or unpasteurized dairy, is crucial as these items can harbor bacteria, viruses, and parasites that are destroyed by cooking or pasteurization. Ingestion of these pathogens can lead to severe gastrointestinal or systemic infections.

A. Phantom breast pain occurs at the mastectomy wound site. B. There is a combination of numbness and pain around the breast incision. C. Lymphedema is observed in the arm on the same side as the mastectomy. D. Wound dressing is saturated with blood every two hours.

Correct Answer is C

Explanation

Choice A rationale

Phantom breast pain is a neuropathic pain phenomenon that can occur after mastectomy, characterized by sensations of pain, itching, or tingling in the removed breast. While distressing for the client, it is a common neurological sequela and not typically considered an acute surgical complication indicating immediate danger.

Choice B rationale

A combination of numbness and pain around the breast incision is expected post-mastectomy. Numbness results from nerve transection during surgery, while pain is an anticipated consequence of tissue injury and inflammation. These are normal postoperative sensations, managed with analgesia, and do not typically signify a complication.

Choice C rationale

Lymphedema, characterized by swelling in the arm on the same side as the mastectomy, indicates a complication. It results from impaired lymphatic drainage due to lymph node removal or damage during surgery. This can lead to chronic swelling, discomfort, and increased risk of infection, requiring immediate intervention to manage and prevent progression.

Choice D rationale

A wound dressing saturated with blood every two hours indicates excessive bleeding, which is a significant complication post-mastectomy. While some serosanguineous drainage is normal, continuous saturation suggests active hemorrhage or a hematoma, requiring immediate assessment and potential surgical intervention to control the bleeding.

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client during the first 24 hours post mastectomy. Which of the following observations made by the nurse should indicate a complication from the mastectomy procedure?

Correct Answer is C

Explanation

A nurse is caring for a client diagnosed with HIV and receiving antiretroviral therapy. The nurse should assess for which potential adverse effects of long-term antiretroviral therapy?

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