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
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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Related Questions
Correct Answer is D
Explanation
A. Administer a stat fluid challenge: This might temporarily improve cardiac output in tamponade, but it is not the primary intervention. The fluid challenge may be used as a temporary measure, but it does not address the underlying cause.
B. Place the patient in a prone position: This is incorrect and could worsen the patient's condition. The patient should be in a semi-recumbent position to decrease venous return and reduce pressure on the heart.
C. Draw a stat CBC: A CBC is not relevant to the immediate management of cardiac tamponade and does not address the urgent need to relieve the pressure on the heart.
D. Perform a stat pericardiocentesis: Pericardiocentesis is the definitive treatment for cardiac tamponade, as it removes the fluid from the pericardial space, relieving the pressure on the heart and allowing it to function properly.
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.
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