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.

Answer and Explanation

The Correct Answer is []

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.

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Correct Answer is D

Explanation

A. Infection: The client’s temperature is only mildly elevated and WBC count is within normal range, which does not strongly suggest infection at this time. Although postoperative clients are always at risk for infection, the assessment data do not indicate this as the most immediate concern.

B. Deep vein thrombosis: The client is postoperative and has reduced mobility, which increases risk for DVT. However, her vital signs do not show signs of venous thromboembolism such as unilateral leg swelling or sudden unexplained tachycardia. While DVT remains a possibility, current findings do not indicate it as the greatest immediate risk.

C. Atelectasis: Atelectasis commonly occurs in the first 24–48 hours after surgery due to shallow breathing and reduced mobility. By postoperative day 3, her respiratory rate and oxygen saturation are stable, and breath sounds have no abnormalities reported. These findings suggest that respiratory complications are not the most urgent issue.

D. Intestinal obstruction: The client has a distended abdomen, persistent hypoactive bowel sounds, no bowel movement for several days, and severe abdominal pain. These findings are concerning for a developing bowel obstruction or postoperative ileus. Increasing distention and poorly responsive pain indicate impaired gastrointestinal motility.

A. Initiate cardiac monitoring B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin 20 units subcutaneously D. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr E. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr F. Insert indwelling urinary catheter G. Blood glucose checks every 4 hr H. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L

Correct Answer is ["A","D","H"]

Explanation

A. Initiate cardiac monitoring: Cardiac monitoring is important because the client has hyperkalemia (potassium 5.5 mEq/L) and is at risk for arrhythmias. Monitoring allows early detection of changes in cardiac rhythm, which can occur rapidly in electrolyte imbalances associated with hyperglycemic crises.

B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L: Potassium replacement is not indicated at this time because the client’s serum potassium is elevated at 5.5 mEq/L. Administering potassium now could worsen hyperkalemia and increase the risk of life-threatening cardiac dysrhythmias.

C. Regular insulin 20 units subcutaneously: Subcutaneous insulin is not appropriate for severe hyperglycemia with ketoacidosis risk, as it has a slower onset and may not provide adequate glycemic control. Intravenous insulin infusion is preferred in this setting to allow rapid titration and prompt reduction of blood glucose and ketone levels.

D. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr: Aggressive IV fluid resuscitation with isotonic saline is indicated for dehydration from hyperglycemia and osmotic diuresis. Calculated fluid replacement helps restore intravascular volume, improve perfusion, and support renal function.

E. Dextrose 5% in water (D5W) intravenous at 5 ml/kg/hr for 4 hr: Dextrose is not indicated initially because the client’s blood glucose is extremely elevated at 468 mg/dL. Dextrose would worsen hyperglycemia at this stage. Dextrose is added later during insulin therapy when glucose levels fall to prevent hypoglycemia while continuing ketone clearance.

F. Insert indwelling urinary catheter: Routine catheterization is not indicated for this client, as there is no urinary retention or obstruction reported. Inserting a catheter unnecessarily increases the risk of infection without improving outcomes in hyperglycemia management.

G. Blood glucose checks every 4 hr: For a client with severe hyperglycemia and suspected DKA or hyperosmolar state, glucose monitoring every 4 hours is insufficient. Hourly monitoring is needed to safely titrate IV insulin and fluids, allowing rapid response to changing glucose and electrolyte levels.

H. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L: Continuous IV insulin infusion is the treatment of choice for severe hyperglycemia with ketones and acidosis. It allows precise titration based on glucose levels while ensuring potassium levels are safe.

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Correct Answer is D

Explanation

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Correct Answer is ["A","D","H"]

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