The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

weigh the client to obtain a baseline for comparison

Insert an indwelling catheter

Draw blood for chemistry studies and a CBC

Administer furosemide 40mg PO

Answer and Explanation

The Correct Answer is A

A.   Weighing the client provides an important baseline for monitoring fluid retention and determining the effectiveness of treatments such as diuretics. Rapid changes in weight can indicate worsening heart failure and fluid accumulation.
B.   Inserting an indwelling catheter is not indicated unless there are concerns about urinary retention or output, which are not the priority here.
C.   Drawing blood for chemistry studies and a CBC is important but it does not directly address the immediate concern of fluid retention and worsening heart failure.
D.   Administering furosemide may be necessary depending on the client's condition, but first establishing a baseline weight is important before making further treatment decisions.

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Correct Answer is C

Explanation

A. While privacy may be important for a patient who is emotionally distressed, the priority is addressing
the client’s emotional state, not the physical environment.
B. This might be helpful later, but the priority is to explore the patient's feelings and concerns regarding their condition first. Immediate emotional support is more important at this stage.
C. When a patient expresses feelings of hopelessness, as in this case, the nurse must assess for potential suicidal ideation. This is a priority to ensure patient safety and to provide necessary psychological support or intervention.
D. While reassurance is important, providing false or unrealistic expectations can lead to further disappointment. The nurse should focus on addressing emotional distress and offering realistic support rather than giving definitive assurances.

A. Prothrombin time, fibrin level and eosinophil count B. Fibrin degradation products, lactic acid and complete blood count C. D-dimer, fibrinogen and fibrin degradation products D. Complete blood count, Complete metabolic panel and prothrombin time

Correct Answer is C

Explanation

A. This test set is incomplete for diagnosing DIC. While PT and fibrinogen are important, the eosinophil count is not a key test for DIC.
B. While fibrin degradation products are useful, lactic acid is not specific for DIC and may indicate other issues. A complete blood count is helpful but not definitive for diagnosing DIC.
C. These are key markers for DIC. An elevated D-dimer indicates clot formation and breakdown, while fibrinogen and fibrin degradation products are used to assess clotting and fibrinolysis, both of which are abnormal in DIC.
D. Complete blood count, complete metabolic panel, and prothrombin time are general tests and can give some clues, but they are not definitive for diagnosing DIC.

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The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?

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The nurse is performing an admission assessment of an older adult client with a history of chronic heart failure. The client exhibits +2 pitting edema of the ankles and bibasilar crackles. Based on these findings what action should the nurse take next?