The nurse has completed an assessment on a client with heart failure and a decreased cardiac output with an ejection fraction of 30%. Which finding should receive the highest priority?
BP 110/62, atrial fibrillation with HR 82, bilateral basilar crackles.
Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
SpO2 92% on 2L nasal cannula, respirations 20/min, 1+ edema of lower extremities.
Confusion, urine output 15 mL over the last 2 hours, orthopnea.
The Correct Answer is D
Choice A reason: While atrial fibrillation, bilateral basilar crackles, and a blood pressure of 110/62 indicate important findings in a client with heart failure, they are not immediately life-threatening compared to the symptoms in choice d. Bilateral crackles suggest fluid overload and pulmonary congestion, which require attention, but the priority should be on more critical signs of decreased perfusion.
Choice B reason: Weight gain of 1 kg in 3 days and mild dyspnea with exercise are signs of fluid retention and worsening heart failure. However, they are not as urgent as the symptoms of confusion and low urine output, which suggest severe hypoperfusion and potential organ failure.
Choice C reason: A SpO2 of 92% on 2L nasal cannula, respirations of 20/min, and 1+ edema of the lower extremities indicate mild hypoxemia and fluid overload. Although these findings are important and need management, they are not as critical as the symptoms in choice d, which suggest severe hypoperfusion and a potential emergency.
Choice D reason: Confusion, urine output of 15 mL over the last 2 hours, and orthopnea are the most concerning findings. Confusion indicates decreased cerebral perfusion, which is a sign of severe heart failure and possibly impending cardiogenic shock. Low urine output (oliguria) suggests poor renal perfusion, indicating that the kidneys are not receiving enough blood flow. Orthopnea (difficulty breathing while lying down) is a classic symptom of severe heart failure and pulmonary congestion. These symptoms suggest that the client is in a critical condition that requires immediate intervention to improve perfusion and prevent further deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Respiratory compromise is the greatest risk for a client with a C4 spinal cord injury. The C4 spinal level is critical for the function of the diaphragm, which is the main muscle responsible for breathing. Injury at this level can impair diaphragmatic function, leading to difficulty in breathing or even respiratory failure. Immediate and continuous monitoring of respiratory status is essential for these patients to ensure adequate ventilation and oxygenation.
Choice B reason: Stress ulcers can develop in patients with spinal cord injuries due to the stress response and immobility. However, they are not the highest immediate risk compared to respiratory compromise, which can be life-threatening if not promptly addressed.
Choice C reason: Paralytic ileus, a condition where the intestines stop moving, can occur in spinal cord injury patients due to disruption of the nervous system control of the gut. While it is a significant concern, it is not as immediately life-threatening as respiratory compromise.
Choice D reason: Spinal shock is a condition that can occur after a spinal cord injury, leading to temporary loss of reflexes below the level of the injury. While it is an important condition to recognize and manage, the most urgent risk for a patient with a C4 injury is respiratory compromise due to the potential impact on breathing.
Correct Answer is D
Explanation
Choice A reason: A decreased heart rate is not a typical outcome of ACE inhibitor therapy. ACE inhibitors primarily work by relaxing blood vessels, which lowers blood pressure. They do not directly affect the heart rate. While some blood pressure medications can influence heart rate, this is not a common effect of ACE inhibitors like lisinopril.
Choice B reason: A decrease in chest pain is also not a primary outcome of ACE inhibitor therapy. While lowering blood pressure can help reduce the workload on the heart and potentially decrease angina (chest pain), this is more of an indirect effect. ACE inhibitors are primarily used for hypertension and heart failure, not specifically for pain relief.
Choice C reason: Hypokalemia, or low potassium levels, is not an expected outcome of taking an ACE inhibitor. In fact, ACE inhibitors can lead to hyperkalemia (high potassium levels) because they decrease aldosterone production, which causes the body to retain potassium. Patients on ACE inhibitors are often monitored for signs of hyperkalemia rather than hypokalemia.
Choice D reason: The correct and expected outcome of taking lisinopril, an ACE inhibitor, is decreased blood pressure. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. By reducing levels of angiotensin II, ACE inhibitors help relax blood vessels, which lowers blood pressure and makes it easier for the heart to pump blood. This is the primary therapeutic effect of the medication.
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