The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Weigh patient using bed scale and restrict oral fluids.

Obtain pulse oximetry levels and assess the respiratory status.

Elevate lower extremity on two pillows while patient is in bed.

Obtain a Physical Therapy consultation to evaluate activity tolerance.

Answer and Explanation

The Correct Answer is B

Choice A reason: Weighing the patient using a bed scale and restricting oral fluids are important interventions for managing fluid balance in heart failure, but they are not the immediate priority. Assessing the respiratory status takes precedence to ensure the patient is not in respiratory distress.

Choice B reason: Obtaining pulse oximetry levels and assessing the respiratory status are priority actions. Dyspnea on exertion and fatigue indicate potential respiratory compromise, and it is crucial to evaluate oxygenation and respiratory function immediately.

Choice C reason: Elevating the lower extremity on two pillows while the patient is in bed can help reduce edema but is not the immediate priority. Respiratory assessment and stabilization take precedence.

Choice D reason: Obtaining a Physical Therapy consultation to evaluate activity tolerance is beneficial for long-term management but is not an immediate priority in acute care. The focus should be on assessing and stabilizing the patient's respiratory and cardiac status.

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Correct Answer is B

Explanation

Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.

Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.

A. Foot ulcers and delayed wound healing B. Stroke prevention and cardiac health C. Retinopathy and nephropathy D. Hypertension management and cholesterol control

Correct Answer is C

Explanation

Choice A reason: Foot ulcers and delayed wound healing are related to diabetes but are considered macrovascular complications. Microvascular complications specifically refer to damage to small blood vessels.

Choice B reason: Stroke prevention and cardiac health are important but are related to macrovascular complications of diabetes. The focus here is on microvascular complications.

Choice C reason: Retinopathy and nephropathy are microvascular complications of diabetes. These conditions result from damage to small blood vessels in the eyes and kidneys, respectively. Diabetic retinopathy can lead to vision loss, while diabetic nephropathy can lead to kidney failure. It is important to monitor for these complications and manage blood glucose levels to prevent or slow their progression.

Choice D reason: Hypertension management and cholesterol control are important for overall cardiovascular health but are related to macrovascular complications. The discussion should focus on microvascular complications specific to diabetes.

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The nurse is admitting an older adult with heart failure to the cardiac unit. The nurse notes dyspnea on exertion, fatigue, and 3+ pitting edema in the ankles. What priority actions will the nurse implement for this patient?

Nursing Test Bank

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