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

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.

Rationale for Correct Choices

• Hypovolemic shock: The client had rapid diuresis after receiving 80 mg IV furosemide, resulting in an output of almost 1 L of urine within 1 hour, followed by a sudden drop to only 30 mL at 0100. The fall in blood pressure from 175/88 to 122/75, rising heart rate, dizziness, thirst, and weak pulses indicate low circulating volume consistent with volume depletion.

• Elevate the client’s feet: Raising the lower extremities promotes venous return to improve cardiac output when circulating volume is reduced. This position can temporarily enhance perfusion to vital organs in early hypovolemia. It is also a non-invasive measure providing symptomatic improvement while other treatments are initiated.

• Administer IV fluids: Excess diuresis from furosemide can lead to acute intravascular depletion, and restoring volume with isotonic fluids helps improve preload and blood pressure. The marked drop in urine output to 30 mL indicates compromised renal perfusion, which requires prompt volume replacement. Improved volume status also stabilizes heart rate and reduces symptoms such as thirst and dizziness.

• Pulse pressure: Narrowing pulse pressure is a key indicator of worsening hypovolemia because falling systolic pressure and compensatory vasoconstriction reduce the difference between systolic and diastolic values. Monitoring trends helps evaluate response to fluid resuscitation. Improvement suggests stabilization of intravascular volume and cardiac output.

• Mental status: Cerebral perfusion is highly sensitive to changes in blood volume, so declining alertness or increasing restlessness may indicate deterioration. Monitoring cognitive status provides early warning of inadequate perfusion or progressing shock. Improvement with treatment reflects recovery of effective circulation.

Rationale for Incorrect Choices

• Septic shock: The client has no fever, elevated WBC count, or infectious symptoms, and the rapid fluid loss following diuresis is a more direct explanation for the decline. The stable temperature and clear lungs further reduce suspicion for infection-related hypotension.

• Cardiogenic shock: The lungs are clear, respiratory rate has normalized, and the initial diuretic improved symptoms, making pump failure less likely. The pattern of high urine output followed by a sharp decline aligns more with fluid depletion than primary cardiac dysfunction.

• Obstructive shock: There are no signs of conditions such as pulmonary embolism or tension pneumothorax, and the vital signs improved rather than deteriorated after diuresis. Clear lung sounds and absence of chest pain argue against mechanical obstruction.

• Administer 1 unit of packed RBCs: There is no evidence of bleeding or anemia, and hemoglobin levels are not provided to justify transfusion. The client’s symptoms align with volume loss from diuresis, not red-cell deficiency.

• Obtain a lactate level: While lactate can help evaluate tissue perfusion, it is not the priority intervention when hypovolemia from medication-induced diuresis is evident. Clinical signs already pinpoint fluid loss as the cause, making fluids and positioning more urgent.

• Administer IV antibiotics: No indicators of infection are present, and antibiotic therapy does not address the current hemodynamic issue. The temperature and assessment findings show no infectious focus requiring treatment.

• Blood culture results: Blood cultures assist in diagnosing sepsis, but there is no clinical suspicion of infection in this scenario. The cause of hypotension is more clearly linked to recent diuresis rather than bacteremia.

• Platelet count: Platelet levels are not relevant to diagnosing or managing hypovolemic shock caused by fluid loss. Platelets would be significant in bleeding disorders, which are not indicated here.

• Temperature: The client’s temperature is stable, and changes would not provide insight into fluid volume status. Temperature monitoring is more appropriate when infection or inflammatory causes are suspected.