Exhibits
The nurse is reviewing the client's information.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Congestive cardiomyopathy is the most likely condition given the client’s symptoms of labored breathing, bilateral leg edema, S3 gallop, and apical pulse displacement—all signs of fluid overload and decreased cardiac output associated with heart failure.
- Applying oxygen helps manage dyspnea and improves tissue oxygenation in clients with heart failure, especially when respiratory rate is elevated and breathing is labored.
- Requesting a chest x-ray allows for visualization of pulmonary congestion or cardiomegaly, both of which are common in heart failure and can guide further treatment decisions.
- Monitoring breath sounds helps detect improvement or worsening of pulmonary congestion, such as crackles or rales, which indicate fluid buildup in the lungs.
- Monitoring urine output evaluates kidney perfusion and fluid status, which reflects the effectiveness of heart failure treatment and overall cardiac output.
- Hypertrophic cardiomyopathy typically presents with exertional syncope or chest pain, not fluid overload signs like leg edema and S3 gallop. Apical displacement also favors dilation rather than hypertrophy.
- Dilated cardiomyopathy overlaps with congestive cardiomyopathy, but the broader term “congestive” aligns more clearly with fluid overload and heart failure signs.
- Restrictive cardiomyopathy involves impaired ventricular filling but does not usually present with displaced apical pulse or bilateral edema in early stages. It is also less common in this clinical setting.
- Starting IV fluids would worsen the client’s condition by increasing preload and exacerbating fluid overload in heart failure.
- Giving the client 80 mg of aspirin is more appropriate in acute coronary syndrome, not in managing cardiomyopathy or fluid retention.
- Preparing for cardioversion is indicated in arrhythmias like atrial fibrillation with hemodynamic instability, not in a hemodynamically stable patient with heart failure.
- Monitoring platelet count is not relevant to evaluating heart failure progression or response to treatment.
- Monitoring temperature is important for infection but does not reflect cardiac or fluid status in this context.
- Monitoring cerebral perfusion pressure is reserved for neurocritical care settings and is not appropriate for routine heart failure monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
Calculation:
Desired dose = 10 mcg.
- Convert the desired dose from micrograms (mcg) to milligrams (mg) to match the available concentration's unit.
Since 1 mg = 1000 mcg,
Desired dose in mg = 10 mcg / 1000 mcg/mg
= 0.01 mg.
Available concentration = 0.02 mg/mL.
- Calculate the volume to administer.
Volume (mL) = Desired dose (mg) / Available concentration (mg/mL)
= 0.01 mg / 0.02 mg/mL
= 0.5 mL.
Correct Answer is D
Explanation
A. PaO₂ 60 mm Hg: A PaO₂ of 60 mm Hg indicates moderate hypoxemia, which is concerning but not the most direct marker of respiratory depression. It reflects impaired oxygenation, but CO₂ retention is more closely associated with respiratory arrest risk.
B. pH 7.30: A pH of 7.30 shows mild acidemia, which may result from respiratory or metabolic causes. While this indicates some imbalance, it does not specifically point to the severity of respiratory depression as much as rising CO₂ levels do.
C. HCO₃ 26 mEq/L (26 mmol/L): This bicarbonate value is within the normal range and does not suggest acute metabolic compensation or decompensation. It offers limited insight into the acute respiratory depression caused by sedatives like midazolam and fentanyl.
D. PaCO₂ 80 mm Hg: This significantly elevated PaCO₂ indicates severe hypoventilation and respiratory depression. Such a high carbon dioxide level can suppress central respiratory drive, impair consciousness, and quickly progress to respiratory arrest if not promptly reversed.
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