The nurse is caring for a client who has a fluid-volume overload related to heart failure (HF) and is admitted to the nursing unit for treatment.
Vital signs are:
Temperature: 98.0 oral
Heart rate (HR) 88 beats/minute
Respiratory rate (RR) 22 breaths/minute
Oxygen saturation: 94% on room air
What is the PRIORITY nursing action?
Insert a 20-gauge peripheral IV catheter
Administer oxygen at 2 liters per minute via nasal cannula
Place the client on a cardiac monitor
Auscultate the client's breath sounds
The Correct Answer is D
A. Insert a 20-gauge peripheral IV catheter: Establishing venous access is necessary for administering intravenous diuretics but is not the most immediate action. Assessment of the clinical status must precede invasive interventions to determine the severity of the fluid overload. The nurse should prioritize gathering objective data on respiratory compromise before performing venipuncture.
B. Administer oxygen at 2 liters per minute via nasal cannula: The current oxygen saturation is 94% on room air, which is generally considered acceptable for many patients. While supplemental oxygen may be indicated later, it is not the most critical first step given these stable saturation levels. Respiratory assessment should guide the necessity and titration of oxygen therapy.
C. Place the client on a cardiac monitor: Continuous cardiac monitoring is important for detecting arrhythmias associated with heart failure or electrolyte shifts. However, it does not provide immediate information regarding the patient's primary risk of pulmonary congestion or respiratory distress. Monitoring is an adjunctive task rather than the primary diagnostic priority.
D. Auscultate the client's breath sounds: Assessing for crackles or diminished sounds is the priority to determine the extent of pulmonary edema. This assessment provides immediate data on the severity of the fluid-volume overload and the risk of respiratory failure. Objective respiratory findings are essential for prioritizing subsequent medical and nursing interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Diltiazem: This calcium channel blocker reduces blood pressure and slows the heart rate, both of which can contribute to orthostatic hypotension. In a 70-year-old patient, the baroreceptor reflex is less efficient, making them more susceptible to syncopal episodes during position changes. Lowering systemic vascular resistance too much can result in an acute drop in cerebral perfusion.
B. Carbidopa/levodopa: This medication is primarily used to treat Parkinson's disease and, while it can cause some hypotension, it is not a primary cardiovascular agent. Its impact on blood pressure is generally less profound than that of diuretics or dedicated antihypertensives. It is less likely than the other choices to be the primary driver of a blood pressure of 88/48.
C. Hydrochlorothiazide: Diuretics reduce the total intravascular volume by promoting the excretion of sodium and water. A decrease in blood volume directly lowers the blood pressure and can lead to dehydration-related syncope. This medication is a very common cause of orthostatic dizziness and falls in the geriatric population.
D. Metoprolol: As a beta-blocker, metoprolol reduces cardiac output and inhibits the compensatory tachycardia usually seen when standing. This prevents the body from quickly adjusting the blood pressure during postural changes, leading to the reported dizziness. The combination of reduced heart rate and reduced force of contraction contributes to the hypotensive state.
E. aspirin: Aspirin is an antiplatelet agent used for the prevention of cardiovascular events and does not have a direct effect on blood pressure. It does not cause vasodilation, volume depletion, or changes in heart rate that would lead to syncope. Its primary side effects are related to gastrointestinal irritation and bleeding risks rather than hemodynamics.
Correct Answer is D
Explanation
A. Nitroglycerin: This vasodilator is used to treat anginal chest pain by reducing preload and dilating coronary arteries. It has no role in the management of atrial fibrillation, which is characterized by an irregularly irregular rhythm. Using a nitrate here would not address the underlying electrical disorganized activity in the atria.
B. Hydrochlorothiazide: As a thiazide diuretic, this medication is used primarily for the long-term management of hypertension and mild fluid retention. It does not possess any antiarrhythmic properties and would not be effective in controlling the ventricular rate. Diuretics are not the standard of care for treating an acute rhythm disturbance on a telemetry strip.
C. Atropine: This anticholinergic agent is indicated for the treatment of symptomatic bradycardia by increasing the heart rate. Atrial fibrillation often requires rate control to prevent tachycardia-induced cardiomyopathy rather than stimulation of a faster rate. Atropine could potentially worsen the clinical situation by causing a dangerously rapid ventricular response.
D. Warfarin: Atrial fibrillation causes blood to pool in the atria, which significantly increases the risk of mural thrombus formation and subsequent embolic stroke. Anticoagulation is a mandatory component of management to prevent these life-altering thromboembolic complications. Warfarin is a standard oral anticoagulant used to maintain a therapeutic INR in patients with this chronic dysrhythmia.
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