The nurse is rounding on a patient diagnosed with heart failure (HF). The patient is receiving 1 liter of 0.9% sodium chloride at 150 ml/hr with two hours left on the infusion. The nurse observes that the patient has a moist cough, distended neck veins, and dyspnea. What actions should the nurse take? Select all that apply by choosing the three highest priority nursing actions for this patient.

Check the patient's temperature

Assess the pulse oximetry reading

Auscultate the lungs

Contact the provider

Change the fluids to 0.45% sodium chloride

Administer furosemide as ordered

Answer and Explanation

Correct Answer : B,C,D

A. Check the patient's temperature: Although assessing temperature is part of a full evaluation, fever is not the priority concern in this scenario. The patient’s moist cough, jugular venous distention, and dyspnea suggest acute fluid overload and worsening heart failure rather than infection. Immediate cardiopulmonary assessment takes precedence.

B. Assess the pulse oximetry reading: Dyspnea and signs of volume overload raise concern for pulmonary edema and impaired oxygenation. Measuring oxygen saturation provides rapid, objective data about respiratory compromise and guides urgent interventions such as oxygen therapy. Hypoxemia must be identified promptly to prevent respiratory failure.

C. Auscultate the lungs: Lung auscultation is essential to assess for crackles, which indicate fluid accumulation in the alveoli due to left-sided heart failure. Detecting pulmonary congestion supports clinical suspicion of fluid overload and helps determine severity, guiding immediate treatment decisions.

D. Contact the provider: The patient is exhibiting signs of acute decompensated heart failure while receiving IV fluids. Prompt provider notification is necessary to obtain orders to adjust or discontinue fluids and initiate diuretic therapy or other interventions to prevent worsening pulmonary edema.

E. Change the fluids to 0.45% sodium chloride: The nurse should not independently change the IV solution without a provider order. Additionally, switching to hypotonic fluids does not address the underlying issue of volume overload and could further complicate the patient’s condition.

F. Administer furosemide as ordered: Although loop diuretics are commonly used in fluid overload, administration depends on an existing order. Since the question prioritizes immediate assessment and escalation, verifying oxygenation and lung status and notifying the provider are the top initial actions unless a standing order is already in place.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Perform passive range of motion (ROM) every 8 hours: Passive ROM helps maintain joint mobility and prevent contractures, but performing it only every 8 hours is insufficient to prevent foot drop in a sedated, mechanically ventilated patient. Frequent, targeted interventions are required to maintain ankle dorsiflexion.

B. Massage the feet every 2 hours: Foot massage may improve circulation and provide comfort but does not actively maintain the ankle in a neutral position. Massage alone is ineffective in preventing the plantarflexion contracture characteristic of foot drop.

C. Elevate bilateral lower legs with pillows: Elevating the legs reduces edema but does not address the position of the ankles. Without maintaining dorsiflexion, the risk of foot drop remains, making elevation alone inadequate as a preventive measure.

D. Place orthopedic splints on the patient's feet: Orthopedic or foot drop splints maintain the ankles in a neutral position, preventing plantarflexion and subsequent contractures. This intervention is standard care for sedated, immobile patients on mechanical ventilation and effectively reduces the risk of foot drop.

A. Tachycardia B. Dyspnea C. Muscle Tremors D. Diaphoretic E. Unable to speak in full sentences F. Nausea

Correct Answer is ["A","B","D","E"]

Explanation

A. Tachycardia: An elevated heart rate is a compensatory response to hypoxemia or increased work of breathing. In COPD exacerbations, tachycardia often accompanies early respiratory distress and signals the body’s attempt to maintain oxygen delivery to tissues.

B. Dyspnea: Shortness of breath or difficulty breathing is a primary and direct indicator of respiratory compromise. Progressive dyspnea reflects increased airway resistance, impaired gas exchange, and impending respiratory failure if not addressed promptly.

C. Muscle Tremors: Muscle tremors are not typically a direct sign of respiratory distress. They may occur from anxiety, medications such as beta-agonists, or metabolic disturbances, but they are not a reliable indicator of worsening pulmonary function.

D. Diaphoretic: Excessive sweating is a common autonomic response to hypoxia, increased work of breathing, or sympathetic activation. Diaphoresis in the context of COPD exacerbation signals significant physiologic stress and potential respiratory compromise.

E. Unable to speak in full sentences: Inability to complete sentences without pausing to breathe indicates severe respiratory effort and decreased ventilatory reserve. This is a critical sign of impending respiratory failure requiring immediate assessment and intervention.

F. Nausea: Nausea may occur due to medications, hypoxia, or anxiety but is not a primary manifestation of respiratory distress. It is a nonspecific symptom and less relevant in assessing acute respiratory compromise.

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Naxlex Comprehensive Predictor Exams

The nurse is developing the plan of care to include prevention of foot drop for a patient on a mechanical ventilator who is sedated. What intervention should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is caring for a patient who was admitted for COPD exacerbation. Which of the following manifestations most likely suggestive of the development of respiratory distress? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse is assessing the level of sedation for a patient who is intubated and receiving mechanical ventilation. The nurse observes that the patient's RASS (see RASS tool below or in the attachment) is +2. What is the nurse's best action?

The nurse is caring for a patient and observes the following rhythm on the monitor (see image below or in the attachment for a 6-second rhythm strip). The patient is alert and oriented x3, has a blood pressure of 105/56 mmHg, and denies chest pain. What action should the nurse take first?

The intensive care unit (ICU) nurse plans care for a patient with a hemodynamic monitoring system for central venous pressure (CVP). In the plan of care, which complications does the nurse monitor for? Select all that apply.

A nurse is planning discharge for a client diagnosed with heart failure. Which of the following discharge instructions should the nurse provide to improve activity intolerance?

A patient is brought to the emergency department by paramedics with a sudden onset of a squeezing, sub-sternal pain that radiates to the left shoulder and jaw. The nurse observes that the patient has diaphoresis. What is the nurse's first action?

The nurse assigned a patient who was diagnosed with a pulmonary embolism. Which of the following potential complication during the treatment for pulmonary embolism should the nurse monitor for?