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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Correct Answer is C

Explanation

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

A. View the rhythm in another chest lead. B. Begin chest compressions at a rate of 120 times a minute. C. Auscultate all chest fields for muffled lung sounds. D. Observe for swelling at the fracture site.

Correct Answer is B

Explanation

A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

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