Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

Decreased dyspnea and orthopnea

HgA1C less than 7

Reduction in peripheral edema

Stabilized or decreased BNP level

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Decreased dyspnea and orthopnea reflect improved lung fluid clearance in heart failure. These symptoms lessen with reduced preload and better cardiac output, key goals indicating effective management and patient comfort.

Choice B reason: HgA1C <7 targets diabetes, not heart failure directly. While glycemic control benefits vasculature, it’s not a primary outcome measure for heart failure, which focuses on fluid and pump function instead.

Choice C reason: Reduced peripheral edema shows less fluid retention, a heart failure goal. It results from improved cardiac output and diuresis, alleviating discomfort and signaling successful treatment of volume overload.

Choice D reason: Stabilized or decreased BNP (<100 pg/mL ideally) indicates lower cardiac stress in heart failure. This biomarker drops with reduced wall tension, reflecting effective therapy and a key outcome measure.

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Correct Answer is D

Explanation

Choice A reason: Vasoconstrictors like oxymetazoline shrink vessels, aiding epistaxis control. It’s a secondary step requiring preparation, not first, as direct pressure is faster, non-invasive, and effective for initial hemostasis in most anterior bleeds.

Choice B reason: Packing with a balloon stops severe bleeding but is invasive and later in management. Pressure is the first, simpler action; packing escalates care unnecessarily before basic measures are tried in acute epistaxis.

Choice C reason: Silver nitrate cauterizes vessels, useful for persistent bleeding. It’s not first, requiring setup and assessment after pressure fails, as most epistaxis resolves with compression, making this a subsequent intervention.

Choice D reason: Squeezing nostrils compresses Kiesselbach’s plexus, stopping most anterior nosebleeds within 10 minutes. It’s the immediate, evidence-based first action, non-invasive, and effective, prioritizing rapid control before escalating to other methods.

A. The patient’s blood pressure is 164/98. B. The patient’s oxygen saturation is 90%. C. The patient reports feeling weak. D. The patient appears somnolent and difficult to arouse.

Correct Answer is D

Explanation

Choice A reason: Blood pressure of 164/98 mmHg is elevated but not immediately life-threatening in respiratory failure. It may reflect stress or chronic hypertension, less urgent than neurologic changes signaling CO2 narcosis.

Choice B reason: Oxygen saturation of 90% is low but manageable with oxygen therapy in respiratory failure. It’s concerning, yet less critical than somnolence, which indicates severe CO2 retention requiring urgent intervention.

Choice C reason: Weakness is nonspecific in respiratory failure, possibly from hypoxia or fatigue. It’s not as immediately alarming as somnolence, which directly reflects brain suppression from high PaCO2, needing prompt reporting.

Choice D reason: Somnolence and difficulty arousing signal CO2 narcosis from hypercapnia (high PaCO2), a medical emergency. It indicates respiratory acidosis impairing brain function, requiring immediate provider notification for ventilatory support.

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Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is D

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