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 C

Explanation

Choice A reason: Platelet transfusions are typically reserved for patients with severe bleeding or extremely low platelet counts. They are not a standard treatment for managing ITP unless there is significant bleeding.

Choice B reason: Plasma albumin is not a treatment for ITP. It is used for other conditions such as hypovolemia and hypoalbuminemia but does not address the underlying immune-mediated destruction of platelets in ITP.

Choice C reason: Intravenous immunoglobulin (IVIG) is a treatment for ITP that helps increase platelet counts by modulating the immune system. It is often used in acute settings to manage severe thrombocytopenia and bleeding.

Choice D reason: Factor D is not related to the treatment of ITP. It is involved in the complement system, which is part of the immune response but does not directly address the platelet destruction seen in ITP.

A. Notify the blood bank of the suspected transfusion reaction. B. Maintain IV access with normal saline infusion. C. Facilitate the transfer of the patient to the critical care unit. D. Recheck identification labels and numbers.

Correct Answer is B

Explanation

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

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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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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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