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.

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.