The vital signs for a client with heart failure (HF), who is admitted to the intensive care unit (ICU), are a temperature of 98.6° F (37°C), heart rate 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50 mm Hg. The nurse determines the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement?

Initiate an IV bolus of 0.9% normal saline 500 mL.

Titrate IV dopamine at 8 mcg/kg/minute.

Administer furosemide 40 mg IV push (IVP).

Encourage a liberal PO fluid intake.

Answer and Explanation

The Correct Answer is C

A. Initiate an IV bolus of 0.9% normal saline 500 mL. The client already has elevated CVP and PAWP, which indicate fluid overload and poor cardiac function. Giving a fluid bolus would worsen pulmonary congestion, edema, and respiratory distress. Fluid restriction, rather than additional IV fluids, is usually necessary in decompensated heart failure.
B. Titrate IV dopamine at 8 mcg/kg/minute. Dopamine is a vasopressor and inotropic agent that increases blood pressure and cardiac output. However, the client has an elevated blood pressure (140/50 mm Hg) and signs of fluid overload, making dopamine unnecessary. Increasing contractility could further stress the failing heart and worsen congestion.
C. Administer furosemide 40 mg IV push (IVP). Furosemide (a loop diuretic) is the best intervention for fluid overload in heart failure. Elevated CVP and PAWP suggest pulmonary congestion and excess intravascular volume, which furosemide helps relieve by reducing preload and promoting diuresis. This intervention improves breathing, reduces blood pressure, and decreases cardiac workload.
D. Encourage a liberal PO fluid intake. Clients with heart failure often require fluid restriction to prevent worsening edema and pulmonary congestion. Encouraging excessive oral fluid intake would worsen fluid overload and should be avoided.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Answer:

Potential Condition:

Acute Adrenal Crisis

The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.

A. Teach communication board use. B. Use antiseptic solution with oral care. C. Recommend hours for visitation. D. Promote uninterrupted periods of sleep.

Correct Answer is B

Explanation

A. Teach communication board use. While nonverbal communication tools are helpful for intubated clients, they do not directly prevent complications associated with mechanical ventilation and ARDS. The priority in this critically ill client is to prevent ventilator-associated pneumonia (VAP) and sepsis-related complications.
B. Use antiseptic solution with oral care. Clients on mechanical ventilation are at high risk for ventilator-associated pneumonia (VAP), which worsens outcomes in ARDS. Using an antiseptic solution (such as chlorhexidine) for oral care reduces bacterial colonization in the oropharynx, decreasing the risk of VAP. This intervention is a key component of ventilator bundle protocols to improve survival rates in critically ill patients.
C. Recommend hours for visitation. While family support is important, setting visitation hours does not directly impact the client's recovery from ARDS and sepsis. Infection prevention and lung protection strategies take higher priority in the acute phase.
D. Promote uninterrupted periods of sleep. Rest is important for critically ill clients, but preventing life-threatening complications such as VAP, sepsis progression, and oxygenation failure takes precedence. Proper oral care with antiseptics directly reduces infection risk and improves patient outcomes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Correct Answer is B

Explanation

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Exhibits Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.