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 C
Explanation
A. Assessing the legs and feet for peripheral edema: While edema is an important indicator of heart failure, it does not provide real-time information about the electrical activity of the heart. Edema is a chronic sign of volume overload rather than an acute indicator of dysrhythmia severity. It is not the most critical assessment prior to antiarrhythmic administration.
B. Checking the results of the most recent ECG: An ECG provides a snapshot of previous electrical activity but may not reflect the patient's current hemodynamic status. The nurse must assess the patient's actual physiological presentation at the moment the medication is being given. Bedside assessment is superior to relying solely on historical diagnostic data.
C. Listening to the apical pulse for a full minute: Antiarrhythmic medications can significantly alter heart rate and rhythm, potentially causing profound bradycardia or new conduction blocks. Assessing the apical pulse for 60 seconds provides the most accurate baseline of the heart's current rate and regularity. This is a mandatory safety step to ensure the patient can tolerate the drug.
D. Taking the blood pressure in both arms: While blood pressure is a vital sign, it is a secondary manifestation of the heart's pumping efficiency rather than a direct measure of the rhythm. A single arm reading is usually sufficient unless a specific vascular discrepancy is suspected. The primary concern with dysrhythmia medications is the heart rate itself.
Correct Answer is B
Explanation
A. Call the cardiologist: Contacting the specialist is necessary for definitive management but is not the most immediate nursing action. Delays in providing basic physiological support while waiting for a physician's response can lead to further myocardial damage. Initial stabilization must occur before coordinating the next level of specialized care.
B. Administer oxygen: Myocardial infarction involves a critical mismatch between oxygen supply and demand in the cardiac tissue. Providing supplemental oxygen increases the concentration of oxygen in the blood to help salvage ischemic myocardium and relieve dyspnea. This is a primary intervention to reduce the severity of the infarct and stabilize the patient.
C. Obtain vital signs: While baseline data is important for monitoring, the patient's immediate report of shortness of breath indicates an acute respiratory and circulatory crisis. Taking blood pressure and temperature does not actively treat the underlying hypoxia or chest pain. Interventions to improve oxygenation should take precedence over data collection during active ischemia.
D. Place the client in a supine position: Lying flat increases venous return and the workload of the heart, which can worsen both chest pain and shortness of breath. Patients in respiratory distress should be placed in a high-Fowler's position to maximize lung expansion and decrease cardiac strain. A supine position is physiologically detrimental during an acute coronary event.
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