A nurse on a medical-surgical unit is caring for a client who has a history of congestive heart failure (CHF).

Exhibits

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 Choices:

Hypovolemic shock: The client’s symptoms at 0100 of dizziness, low urine output (30 mL in the last hour) are indicative of hypovolemic shock likely due to aggressive diuresis from the 80 mg IV furosemide administered. Fluid volume depletion leads to reduced circulating blood volume, resulting in these symptoms, which are consistent with hypovolemic shock.
Elevate the client's feet: Elevating the client’s feet is a key intervention to improve venous return, which can increase blood flow to the heart and improve circulation. This is particularly useful in hypovolemic shock to promote better blood flow and tissue perfusion.
Administer IV fluids: IV fluids are critical for restoring the lost fluid volume in hypovolemic shock. Given the low urine output and signs of dehydration, fluid resuscitation will help stabilize the client’s hemodynamic status by increasing circulating volume.
Mental status: Mental status is a key parameter to monitor in shock states. Decreased cerebral perfusion due to hypovolemia can lead to confusion, agitation, or lethargy. Regular monitoring will help assess if the shock is worsening and if more aggressive interventions are needed.
Pulse pressure: Pulse pressure (the difference between systolic and diastolic blood pressure) is often narrowed in hypovolemic shock due to reduced stroke volume. Monitoring pulse pressure helps assess the severity of shock and the effectiveness of interventions such as fluid resuscitation.

Rationale for Incorrect Choices:

Cardiogenic shock: Cardiogenic shock occurs when the heart is unable to pump effectively, leading to inadequate tissue perfusion. While the client does have a history of heart failure, the current presentation, including fluid retention, dizziness, and low urine output, is more indicative of hypovolemic shock.
Obstructive shock: Obstructive shock occurs due to a physical obstruction in blood flow (e.g., pulmonary embolism, cardiac tamponade, or tension pneumothorax). The client’s symptoms do not suggest any form of obstruction; they are consistent with fluid volume depletion.
Septic shock: Septic shock is caused by widespread infection leading to systemic inflammation and vasodilation. The client does not show signs of infection (such as fever or abnormal WBC count) or sepsis, making septic shock unlikely.
Administer 1 unit of packed RBC: This client’s condition is related to fluid loss, not blood loss, so administering blood products is not appropriate. The priority in hypovolemic shock is to restore fluid volume, not blood volume.
Administer IV antibiotics: IV antibiotics are used for treating infections, particularly in cases of septic shock. The client does not exhibit signs of infection (such as fever or elevated WBC), so the use of antibiotics is not warranted here.
Obtain a lactate level: Lactate levels are useful in diagnosing septic shock and assessing tissue hypoxia. While lactate levels can be elevated in shock conditions, the primary cause here appears to be fluid loss, so lactate measurement is not the priority.
Blood culture results: Blood cultures are used to diagnose infections or sepsis. Since the client is not showing signs of infection (such as fever or elevated WBC), blood cultures are not necessary.
Platelet count: Platelet count is relevant in conditions that involve bleeding or clotting disorders. The client does not exhibit signs of a clotting issue or bleeding; therefore, monitoring platelets is not required.
Temperature: Temperature monitoring is important in septic shock to identify infection. However, the client’s temperature is within a normal range 36.2, and there are no indications of infection or systemic inflammation.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

Pain level: The client is experiencing significant chest pain (7/10) radiating to the left arm, which is a classic sign of potential myocardial infarction (MI). Managing pain is the priority to reduce discomfort and prevent further cardiac stress while simultaneously stabilizing the patient.
ECG results: The ECG findings of tachycardia with ST segment elevation and T wave changes indicate a possible acute myocardial infarction (STEMI). Immediate attention to the ECG results is critical for confirming the diagnosis and guiding the appropriate emergency interventions, such as the administration of thrombolytics or preparation for angioplasty.

Rationale for Incorrect Choices:

Diaphoresis: Diaphoresis (excessive sweating) is a sign of myocardial infarction and should be addressed as part of the overall clinical assessment. However, addressing the pain and confirming the diagnosis with an ECG are more urgent initial steps.
Nausea: Nausea is a common symptom in myocardial infarction, but it is not the immediate priority. Pain relief and stabilization of the heart's function should take precedence. Nausea can be managed after addressing the more critical issues.
Cholesterol level: Elevated cholesterol levels, while important for long-term management of hyperlipidemia and cardiovascular risk, are not an immediate priority in this acute presentation.
Pedal pulses: While weak pedal pulses are noted, they are not as urgent as managing the chest pain and confirming the diagnosis with an ECG. Pedal pulses can be monitored during ongoing assessment, furthermore the capillary refill is < 2 seconds indicating adequate perfusion.

A. Cardiac findings B. Neurologic assessment C. Temperature D. Respiratory characteristics E. Urinalysis F. Cardiac rhythm. G. Breath Sounds H. Bowel sounds I. Respiratory rate

Correct Answer is ["A","C","D","E","G","I"]

Explanation

Rationale for Correct Choices:

A. Cardiac findings: The client has signs of fluid retention, including jugular vein distention (JVD) and periorbital edema, suggesting potential heart failure. Monitoring the heart and assessing for potential complications such as arrhythmias or decreased cardiac output is necessary.

B. Neurologic assessment: The client is alert and oriented to person, place, and time, with no signs of confusion or altered mental status. Neurological assessment does not need to be prioritized at this time.

C. Temperature: The elevated temperature of 38.8°C (101.8°F) could indicate an underlying infection. Given the client's recent history of strep throat and the signs of infection in the urine (positive nitrites and leukocyte esterase), a urinary tract infection (UTI) could be a potential cause for the fever.

D. Respiratory characteristics: The client has crackles bilaterally, labored breathing, and low oxygen saturation (90% on room air), which suggest respiratory distress. These findings need further follow-up.

E. Urinalysis: The urinalysis shows dark red color (indicative of hematuria), positive nitrites, positive leukocyte esterase, and blood in the urine. These results suggest a urinary tract infection (UTI) and possible kidney involvement. The reddish-brown urine may also require further assessment to rule out hemolysis or muscle injury.

F. Cardiac rhythm: The client’s heart rhythm is described as normal sinus rhythm (NSR) with a rate of 88/min. There are no immediate concerns about arrhythmias at this time, and the heart rate is within normal limits.

G. Breath sounds: The presence of crackles on auscultation in both lungs indicates possible pulmonary edema or fluid overload, which is commonly seen in heart failure. Follow-up is required to assess for worsening respiratory status and need for intervention.

H. Bowel sounds: The client's bowel sounds are normal, with no signs of gastrointestinal distress or obstruction. There is no indication of a problem in the GI system.

I. Respiratory rate: The client's respiratory rate is 26/min, which is elevated. This, combined with shortness of breath and labored respirations, indicates significant respiratory distress. It is a key indicator of impaired gas exchange or increased work of breathing.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client’s dropdown followed by the client's dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse is caring for a client in the emergency department. Exhibits Identify the findings that require follow-up. Select all that apply.

Correct Answer is ["A","C","D","E","G","I"]

Explanation

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