The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

Pallor and/or cyanosis of extremities

Orthopnea, peripheral edema, crackles

Dizziness, syncope. palpitations

PAWP of 12 and CVP of 6

Answer and Explanation

The Correct Answer is B

A. Pallor and/or cyanosis of extremities: While pallor and cyanosis can indicate severe heart failure, they are not early signs. These symptoms usually appear later in the disease process.

B. Orthopnea, peripheral edema, crackles: These are early signs of heart failure indicating fluid overload due to decreased cardiac output. Orthopnea is difficulty breathing when lying flat, peripheral edema is swelling in the limbs, and crackles indicate fluid in the lungs.

C. Dizziness, syncope, palpitations:These symptoms can occur in heart failure but are not specific to fluid overload; they are more indicative of decreased cardiac output and possible arrhythmias.

D. PAWP of 12 and CVP of 6: These values are within normal limits. PAWP (Pulmonary Artery Wedge Pressure) and CVP (Central Venous Pressure) would be elevated in fluid overload.

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Correct Answer is C

Explanation

A. PT/INR: PT/INR is used to assess clotting function and liver synthetic function but does not directly relate to the symptoms of lethargy and confusion.

B. Urea: Urea levels are related to kidney function and protein metabolism but do not directly explain the symptoms of encephalopathy.

C. Ammonia: Elevated ammonia levels in cirrhosis can lead to hepatic encephalopathy, which presents as lethargy and confusion. The liver is unable to convert ammonia to urea, leading to its accumulation in the blood.

D. Albumin: Albumin levels are important in assessing nutritional status and fluid balance in cirrhosis but do not directly cause lethargy and confusion.

A. Notify the health care provider B. Call respiratory therapy to obtain the pressure within the balloon C. Add air to the balloon port D. Remove air from the balloon port

Correct Answer is B

Explanation

A. Notify the health care provider: While it may eventually be necessary to notify the healthcare provider, the immediate action should involve confirming the balloon pressure, which is within the scope of respiratory therapy.

B. Call respiratory therapy to obtain the pressure within the balloon: This is the most appropriate action. Respiratory therapists are skilled in managing and measuring the cuff pressure to ensure it is within the correct range (typically 20-30 cm H2O).

C. Add air to the balloon port: Adding air without knowing the current pressure could lead to over inflation, which might cause tracheal injury.

D. Remove air from the balloon port: Similarly, removing air could lead to underinflation, increasing the risk of aspiration or inadequate ventilation.

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The nurse is assessing a patient for heart failure (HF). Which early findings would indicate decreased cardiac output and a potential for fluid overload from heart failure?

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Naxlex Comprehensive Predictor Exams

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