The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Avoid positioning the client supine.

Limit the client's activity level.

Administer supplemental oxygen at all times.

Teach the client deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is A

A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.

B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.

C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.

D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.

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Correct Answer is B

Explanation

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.

A. Hypertension B. Severe anemia C. Sepsis D. Hyperthyroidism

Correct Answer is A

Explanation

A. Hypertension: This is not a cause of high-output heart failure. Hypertension typically leads to low-output heart failure due to increased afterload, which causes the heart to work harder.

B. Severe anemia: Severe anemia causes high-output heart failure because the body compensates for the decreased oxygen-carrying capacity by increasing cardiac output.

C. Sepsis: Sepsis can lead to high-output heart failure as the body attempts to maintain perfusion in the face of widespread vasodilation.

D. Hyperthyroidism: Hyperthyroidism increases metabolic demands, which can cause high-output heart failure as the heart attempts to meet the increased needs.

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The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Which of the following is not a cause of high-output heart failure?

Correct Answer is A

Explanation

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