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 ["A","C","D"]

Explanation

A. Increased respiratory rate - Fluid overload can lead to pulmonary edema, which causes difficulty breathing and an increased respiratory rate.
B. Increased temperature - Fluid overload does not typically cause a temperature increase. A fever may indicate infection rather than fluid overload.
C. Increased heart rate - The body compensates for fluid overload by increasing the heart rate to maintain cardiac output.
D. Increased blood pressure - Fluid overload leads to increased blood volume, which results in elevated blood pressure.
E. Increase hematocrit - Hematocrit usually decreases with fluid overload, as it is diluted by the extra fluid volume.

A. 119 seconds B. 98 seconds C. 37 seconds D. 69 seconds

Correct Answer is D

Explanation

A. A value of 119 seconds would indicate a therapeutic or even elevated level of heparin, as it is much higher than the normal aPTT range.
B. A value of 98 seconds is still above the normal aPTT range, suggesting that the heparin level is therapeutic, or even too high, but not sub-therapeutic.
C. This is just slightly above the normal range and might be considered a therapeutic range for someone
on heparin, but it’s not sub-therapeutic.
D. This aPTT value is above the normal range but likely not high enough to indicate therapeutic heparin levels, which should typically be between 1.5 to 2.5 times the normal aPTT. A sub-therapeutic level could be indicated with a lower value.

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			Male: 14- 17.3 g/dL
Hematocrit	26%	24%	Female: 36%-48% Male: 42%-52%
Platelets	35,000mm3	20,000mm3	150,000- 450,000mm3
RBC	4.5 mm3	3mm3	Female: 4.01-5.51 million/mm3 Male: 4.51-

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is caring for a client receiving a heparin infusion for disseminated intravascular coagulation (DIC). Which of the following lab results would indicate a sub-therapeutic level? An activated partial thromboplastin time (aPTT) of :……. (normal value: 25-35 seconds)

Correct Answer is D

Explanation

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