br>History and Physical
BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min
Temperature 37.2" C (99.0° F)
A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the
client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Administer furosemide.
Withhold digoxin.
Withhold spironolactone.
Administer ferrous sulfate.
The Correct Answer is B
A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.
B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.
C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.
D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.
B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.
C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.
D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.
Correct Answer is C
Explanation
A. Dependent edema is a sign of fluid overload or right-sided heart failure but is not immediately life-threatening.
B. A pericardial friction rub is a characteristic finding of pericarditis but does not indicate imminent compromise.
C. A paradoxical pulse (pulsus paradoxus) can indicate cardiac tamponade, a life-threatening complication of pericarditis. Prompt recognition and intervention are critical.
D. Substernal chest pain is a common symptom of pericarditis and should be addressed, but it is not as immediately dangerous as signs of cardiac tamponade.
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