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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?

A.

Pallor and/or cyanosis of extremities

B.

Orthopnea, peripheral edema, crackles

C.

Dizziness, syncope. palpitations

D.

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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Related Questions

Correct Answer is A

Explanation

A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.

B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.

C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.

D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.

Correct Answer is ["50"]

Explanation

Available: Octreotide 0.5 mg in 100 mL of fluid

Calculation:

Convert the available dose to mcg:

  • 0.5 mg = 500 mcg

Determine the concentration:

  • 500 mcg in 100 mL = 5 mcg/mL

Calculate the infusion rate:

  • Desired rate: 50 mcg/hour
  • Infusion rate (mL/hour) = Desireddose(mcg/hour)÷ Concentration(mcg/mL)

= 50 mcg/hour ÷ 5 mcg/Ml

= 10 mL/hour

The infusion rate of 10 mL/hour will deliver 50 mcg/hour of Octreotide, as prescribed.

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